[ { "id": "multiclinsum_test_3352_en.txt", "fulltext": "This is a healthy 22-year-old gentleman who presented with chronic hematospermia for 5 years. This has been a consistent problem, present with every ejaculation. It has severely and negatively affected his sexual life. He has no chronic medical issues apart from major depressive disorder for which he takes Trazodone and Escitalopram. He has had no previous surgeries. Interestingly, he has a congenitally absent left kidney. He denies previous sexually transmitted illnesses (STIs). The patient has denied urinary symptoms or urethral discharge at any point, and he has adequate erections for sexual intercourse without any concern for erectile dysfunction. General physical examination and genital/prostate examination are within the normal limits without any notable findings.\n\nIn attempts to address his hematospermia, the patient has received multiple courses of antibiotics (Doxycycline, Trimethoprim/Sulfamethoxazole, and Fluoroquinolones) without benefit over the past several years. A trial of Finasteride was offered but the patient declined this due to concern of possible sexual side effects at his young age.\n\nOther aspects of his work-up after presentation including labs and imaging. Serum creatinine was normal. Urinalysis, urine culture, Chlamydia/gonorrhea, and other STI tests came back negative. An ultrasound of the scrotum was performed which was unremarkable. Given the plethora of negative tests and persistent symptoms, it was agreed upon to perform a cystoscopy which was also unremarkable. At this point, Magnetic Resonance Imaging (MRI) of the pelvis was ordered and showed no evidence of tumors, cysts, or vascular abnormalities; and revealed distension of the left SV with blood. The right SV was normal.\n\n\nThe options of treatment were discussed with the patient and given the chronicity of the condition and its negative effect on his sexual life. Several treatment options were discussed with the patient. TRUS-guided SV puncture with drug instillation, TRUS-guided cyst aspiration and transurethral resection with deroofing were discussed as less morbid interventions but associated with higher failure rate. He opted for surgical removal of the left SV, despite potential for higher morbidity and potential impotence or ejaculatory dysfunction, due to his many year struggle with the condition. This was performed as a robotic-assisted laparoscopic left seminal vesiculectomy.\n\nTechnique of the primary procedure\nThe patient underwent standard induction, position preparation and draping. He was placed in the 30-degree Trendelenburg position. An Xi DaVinci robot was utilized with port placement identical to that of a robotic prostatectomy. After access was obtained and we had visualization, the small bowel was mobilized cranially. The sigmoid colon was then mobilized, exposing the cul-de-sac. The left SV was exposed and mobilized using blunt dissection and bipolar cautery to avoid neurovascular injury. The SV was traced back and dissected to the base of seminal vesicle duct. The duct of the SV was then ligated using 2-0 Monocryl suture. Transection was completed sharply, and the SV was then sent for pathologic examination. Additional examination and hemostasis using bipolar cautery and hemostatic agents. The peritoneum was then closed over the operative field once packed with SURGIFLO ® Hemostatic Matrix mixed with thrombin.\n\nOutcome and follow up\nThe patient was discharged home in good condition the next morning. He presented with abdominal pain 2 days after the procedure with abdominal pain and no fever or urinary symptoms. Unfortunately, CT scan of the abdomen & pelvis revealed pelvic hematoma. On the 3rd day post-operatively, he was brought back to the operative room and underwent robotic-assisted laparoscopic exploration.\n\nTechnique for robotic exploration\nFollowing induction, positioning and draping, the port sites of the prior operation were opened and canula inserted. Intermediate Trendelenburg (15–20-degree) was used. Insufflation then proceeded normally. The hematoma was evacuated with the Stryker® large 10 mm suction device. The peritoneum in the Cul-de-Sac was reopened and additional hematoma was evacuated upon which, a small bleeding vessel was identified in the surgical field. This was controlled safely with bipolar cautery and a drain was placed in immediate vicinity. The field was then repacked with SURGIFLO® Hemostatic Matrix mixed with thrombin to limit any further bleeding. The peritoneum was again reconstituted, and the operation was concluded uneventfully following port closure.\n\nFollowing the procedure, the patient was feeling well and was discharged home the next day in good condition. At 6 months follow-up, the patient has no pain or urinary symptoms. He still maintains normal erections with maintenance of baseline ejaculatory volume and force without hematospermia. The patient was satisfied with the results of the procedure. Pathological examination revealed left SV with congestion and focal mild chronic inflammation but was negative for malignancy.", "summary": "We present an unusual case of chronic hematospermia for 5 years in a 22-year-old patient, which failed conservative medical management. MRI was conducted which revealed left seminal vesicle (SV) distended with blood and a normal right SV. He was treated with robotic unilateral seminal vesiculectomy (RUSV). At 6 months follow-up, ejaculation was normal and hematospermia resolved.", "subclaim_evaluations": [ { "subclaim": "The patient is a 22-year-old male.", "support_label": "supported" }, { "subclaim": "The patient had chronic hematospermia for 5 years.", "support_label": "supported" }, { "subclaim": "The patient failed conservative medical management.", "support_label": "supported" }, { "subclaim": "MRI was conducted.", "support_label": "supported" }, { "subclaim": "The left seminal vesicle was distended with blood.", "support_label": "supported" }, { "subclaim": "The right seminal vesicle was normal.", "support_label": "supported" }, { "subclaim": "The patient was treated with robotic unilateral seminal vesiculectomy.", "support_label": "supported" }, { "subclaim": "At 6 months follow-up, hematospermia resolved.", "support_label": "supported" }, { "subclaim": "At 6 months follow-up, ejaculation was normal.", "support_label": "supported" } ] }, { "id": "multiclinsum_test_1265_en.txt", "fulltext": "We report on an 81-year-old woman with no relevant comorbidities and a smoking history of 5 pack years. In 2006 she was diagnosed with a pT2a, pN0 (0/5), cM0, UICC stage IB squamous cell carcinoma of the left upper lung lobe, for which she underwent a double-sleeve lobectomy with lymphadenectomy. During 5 years of follow-up, no relapse occurred. In April 2019, the patient presented with a post-stenotic pneumonia. Computed tomography of the chest showed a mass in the left lung. Radiological staging with whole-body 18F-FDG-PET/CT and brain MRI showed metastatic disease with a strongly metabolically active primary tumor (SUVmax 16.7), pleural carcinomatosis on the left side (SUVmax 9.4), periclavicular lymph node metastases on the left side (SUVmax 9.9), and bone metastases in the 12th thoracic and 4th lumbar vertebra (SUVmax 5.0 and 4.6, respectively) . Histology of bronchoscopic biopsy specimens revealed squamous cell carcinoma, which could be interpreted as recurrence or as a second lung cancer, taking into consideration the 13-year-long disease-free interval. The immunohistochemistry for programmed cell death ligand 1 (PD-L1) revealed an expression in 20% of tumor cells and in < 10% of immune cells. In order to complete our internal lung cancer diagnostic algorithm (Treichler G, manuscript in preparation), we performed next-generation sequencing using the FDA-approved FoundationOne®CDx assay. We found a structural aberration on the long arm of chromosome 3 (3q) with amplifications of the genes , SOX2, and FGF12; mutations of TP53, ATRX1, RB1, and, subclonally, PIK3CA; a stable microsatellite state (MSS), and a low tumor mutational burden (5 Muts/Mb).\nBased on the recommendation by our multidisciplinary tumor board, a therapy regimen consisting of pembrolizumab, carboplatin and paclitaxel in analogy to the KEYNOTE-407 study was suggested. The patient declined systemic treatment. She was thus referred for radiotherapy in order to achieve local control, due to the central localization of the tumor with associated risk of post-stenotic pneumonia and bleeding. The patient underwent conventionally fractionated radiotherapy of the principal pulmonary tumor bulk with palliative intention with 3 Gy in 12 fractions, resulting in a total dose of 36 Gy, using Volumetric Modulated Arc Therapy (VMAT, RapidArc™). Radiotherapy was well tolerated, with esophagitis grade 2 according to the Common Terminology Criteria for Adverse Events (CTCAE) version 5.0. Four weeks after the last day of radiotherapy, restaging was performed with 18F-FDG-PET/CT. A partial remission of the tumor bulk, the nodal metastases and, surprisingly, also of the vertebral lesions was shown . Of note, the supraclavicular lymph nodes and the two bone metastases in the spinal column had not been included in the irradiation field with scatter doses of 0.201 Gy, 0.093 Gy, and 0.021 Gy on the lymph nodes, vertebra Th12, and L4, respectively . Furthermore, no antiresorptive medication had been administered. Due to the remission and the lack of tumor-related symptoms, systemic treatment—although no longer refused by the patient—was withheld. The patient underwent radiological follow-up, during which further decrease in tumor size and complete metabolic remission of the bone, pleural and lymph node metastases was seen . Currently, 25 months after radiotherapy, the patient is still free of symptoms and has an Eastern Cooperative Oncology Group (ECOG) Performance Status of 0.", "summary": "Here, we report on the case of an 81-year-old woman with recurrent metastatic squamous cell carcinoma of the lung with mediastinal tumor bulk, lymph node and bone metastases. The patient refused to undergo systemic treatment, and palliative stereotactic radiotherapy of the mediastinal tumor was performed. At restaging with FDG-PET/CT, the patient presented with a decrease in size and FDG-avidity both of the irradiated site and of the lymph node and bone metastases (which did not receive radiotherapy). At 25 months after radiotherapy, the patient is still in remission at all sites.", "subclaim_evaluations": [ { "subclaim": "The patient is an 81-year-old woman.", "support_label": "supported" }, { "subclaim": "She has recurrent metastatic squamous cell carcinoma of the lung.", "support_label": "supported" }, { "subclaim": "The tumor has mediastinal bulk.", "support_label": "supported" }, { "subclaim": "The patient has lymph node metastases.", "support_label": "supported" }, { "subclaim": "The patient has bone metastases.", "support_label": "supported" }, { "subclaim": "The patient refused systemic treatment.", "support_label": "supported" }, { "subclaim": "Palliative stereotactic radiotherapy of the mediastinal tumor was performed.", "support_label": "not_supported" }, { "subclaim": "At restaging with FDG-PET/CT, the irradiated site decreased in size.", "support_label": "supported" }, { "subclaim": "At restaging with FDG-PET/CT, the irradiated site showed decreased FDG-avidity.", "support_label": "supported" }, { "subclaim": "Lymph node metastases showed decreased FDG-avidity.", "support_label": "supported" }, { "subclaim": "Bone metastases showed decreased FDG-avidity.", "support_label": "supported" }, { "subclaim": "The patient is still in remission at all sites.", "support_label": "supported" }, { "subclaim": "The remission has lasted 25 months after radiotherapy.", "support_label": "supported" } ] }, { "id": "multiclinsum_test_64_en.txt", "fulltext": "A 68-year-old man was admitted to our department with chief complaint of a scrotal mass, which had enlarged gradually over a 6 month duration. Physical examination revealed a round, nontender mass, approximate to the size of a tennis ball, occupying the whole left scrotum . Scrotal USG showed a heterogenous lesion in the left hemiscrotum arising from layer of tunica albuginea. The level of serum tumor markers, including alpha-fetoprotein, human chorionic gonadotropin and lactic acid dehydrogenase, were within the normal range. CT scans of the chest, abdomen did not reveal any lymphadenopathy or mass lesion. There was no evidence of lymph node enlargement or ascites. The patient underwent a high inguinal orchidectomy which was further send for HPE examination (, , ).", "summary": "A 68 years male presented with a gradually enlarging scrotal mass over a period of 6month duration. On examination a mass was felt (5 cm × 4 cm) occupying left side of scrotum and abutting the lower pole of left testis. Left inguinal orchidectomy along with excision of mass was done. HPE revealed a spindle cell pattern with low cellularity and Immunohistochemical analysis revealed the tumor reactive for CD 117 and CD 34 which is suggestive of GIST.", "subclaim_evaluations": [ { "subclaim": "The patient is a 68-year-old male.", "support_label": "supported" }, { "subclaim": "He had a gradually enlarging scrotal mass.", "support_label": "supported" }, { "subclaim": "The mass had been present for 6 months.", "support_label": "supported" }, { "subclaim": "On examination, a 5 cm × 4 cm mass was felt.", "support_label": "not_supported" }, { "subclaim": "The mass occupied the left side of the scrotum.", "support_label": "supported" }, { "subclaim": "The mass abutted the lower pole of the left testis.", "support_label": "not_supported" }, { "subclaim": "A left inguinal orchidectomy was performed.", "support_label": "supported" }, { "subclaim": "The mass was excised.", "support_label": "supported" }, { "subclaim": "Histopathological examination revealed a spindle cell pattern.", "support_label": "supported" }, { "subclaim": "The tumor showed low cellularity.", "support_label": "not_supported" }, { "subclaim": "Immunohistochemical analysis showed the tumor was reactive for CD117.", "support_label": "not_supported" }, { "subclaim": "Immunohistochemical analysis showed the tumor was reactive for CD34.", "support_label": "not_supported" }, { "subclaim": "The findings are suggestive of gastrointestinal stromal tumor (GIST).", "support_label": "not_supported" } ] }, { "id": "multiclinsum_test_2479_en.txt", "fulltext": "The 70-year-old female was electively admitted to our institution for an open pancreaticoduodenectomy for the treatment pancreatic adenocarcinoma. The patient had the chief complaint of painless jaundice.\nThe jaundice had arisen insidiously over a 6-mo period. It was associated with weight loss and poor appetite. Extensive investigations had been performed, including computed tomography of the chest, abdomen and pelvis, magnetic resonance cholangiopancreatography, endoscopic ultrasound, endoscopic retrograde cholangiopancreatography, and positive emission topography scan. She had also had a diagnostic laparoscopy.\nThe patient’s only past medical history included an open appendectomy for appendicitis.\nAs per unit and hospital protocol, immediately post-operation, the patient was admitted to the intensive care unit (ICU) with nasojejunal (NJ) feeding tube. EN commenced 6 h post-operation at 30 mL/h. She required no vasopressor support and on day 1 had the feed rate increased. She was transferred to the surgical ward and the only concern in the immediate post-operative period was high nasogastric (NG) output. This initially improved, and slowly oral intake was introduced. She was prescribed an osmotic laxative at this time.\nOn day 5, the patient developed nausea and vomiting, with increasing pain in her central abdomen. Clinically, she had a mild tachycardia and central abdominal tenderness. The initial differential diagnosis of the presentation was postoperative anastomotic leak, particularly supported by the sudden deterioration in clinical picture and timing of the deterioration. Other differentials included postoperative collection and small bowel obstruction, potentially caused by internal hernia. To investigate, a computed tomography was organized; the finding was a large volume of fluid in distal thoracic esophagus and stomach. The tip of the NJ feeding tube was located appropriately within the efferent small bowel loop. There were also features of proximal to mid small bowel obstruction with faecalisation . The transition point was not clearly defined . Adhesions were postulated as a possible cause.", "summary": "The 70-year-old female presented to our institution for a pancreaticoduodenectomy (Whipple's procedure) for pancreatic adenocarcinoma. On day 5 post-operative, having failed to progress and developing symptoms of small bowel obstruction, she underwent a computed tomography scan, which showed features of mechanical small bowel obstruction. Following this, she underwent an emergency laparotomy and small bowel decompression. The recovery was long and protracted but, ultimately, she was discharged home. A literature search of reports from 1966-2020 was conducted in the MEDLINE database. We identified eight articles describing a total of 14 cases of small bowel obstruction secondary to enteral feed bezoar. Of those 14 cases, all but 4 occurred after upper gastrointestinal surgery; all but 1 case required further surgical intervention for deteriorating clinical picture. The postulated causes for this include pH changes, a reduction in pancreatic enzymes and gastric motility, and the use of opioid medication.", "subclaim_evaluations": [ { "subclaim": "The patient was a 70-year-old female.", "support_label": "supported" }, { "subclaim": "She underwent a pancreaticoduodenectomy (Whipple's procedure).", "support_label": "supported" }, { "subclaim": "The procedure was for pancreatic adenocarcinoma.", "support_label": "supported" }, { "subclaim": "On day 5 post-operative, she developed symptoms of small bowel obstruction.", "support_label": "supported" }, { "subclaim": "A computed tomography scan showed features of mechanical small bowel obstruction.", "support_label": "supported" }, { "subclaim": "She underwent an emergency laparotomy.", "support_label": "not_supported" }, { "subclaim": "She underwent small bowel decompression.", "support_label": "supported" }, { "subclaim": "A literature search was conducted in the MEDLINE database.", "support_label": "not_supported" }, { "subclaim": "The search covered reports from 1966 to 2020.", "support_label": "not_supported" }, { "subclaim": "Eight articles were identified.", "support_label": "not_supported" }, { "subclaim": "The articles described a total of 14 cases of small bowel obstruction secondary to enteral feed bezoar.", "support_label": "not_supported" }, { "subclaim": "All but 4 of the 14 cases occurred after upper gastrointestinal surgery.", "support_label": "not_supported" }, { "subclaim": "All but 1 case required further surgical intervention.", "support_label": "not_supported" }, { "subclaim": "The surgical intervention was due to a deteriorating clinical picture.", "support_label": "supported" }, { "subclaim": "Postulated causes include pH changes.", "support_label": "not_supported" }, { "subclaim": "Postulated causes include a reduction in pancreatic enzymes.", "support_label": "not_supported" }, { "subclaim": "Postulated causes include a reduction in gastric motility.", "support_label": "not_supported" }, { "subclaim": "Postulated causes include the use of opioid medication.", "support_label": "not_supported" } ] }, { "id": "multiclinsum_test_1868_en.txt", "fulltext": "A 79-year-old Black female patient was referred for percutaneous LAAO. Past medical history was significant for mitral regurgitation, tricuspid regurgitation, and persistent atrial fibrillation complicated by recurrent significant gastrointestinal haemorrhage on anticoagulation secondary to diverticulosis. Five months prior to referral, she underwent surgical mitral and tricuspid valve repair, as well as LAA ligation with 35 mm AtriClip due to elevated stroke risk (CHA2DS2-VASc score 5) with intolerance to oral anticoagulation. Initial pre-procedural clinical examination revealed a haemodynamically stable, well-appearing female with regular heart rate and irregular rhythm. Pre-operative laboratory assessment revealed normal kidney function (serum creatinine 0.81 mg/dL) and mild anaemia (haemoglobin 10.8 g/dL, reference 12.0–15.0 g/dL). Intra-operative transoesophageal echocardiogram (TEE) demonstrated closure of the LAA. However, 40-day post-operative TEE and cardiac computed tomography (CT) imaging demonstrated a significant persistent communication between the left atrium and LAA with no evidence of LAA thrombus ( and ). After comprehensive review of the TEE and CT scan images, we felt that a LAAO device could be used to achieve adequate occlusion of the residual LAA pouch. For LAAO device implantation, trans-septal atrial imaging was performed using fluoroscopic and TEE guidance, with a mid-septal puncture chosen using intracardiac ultrasound guidance. Intra-procedural TEE was used for sizing of the LAA, and based on these measurements, a 27 mm LAAO device (WATCHMAN™) was selected and deployed, with all the P.A.S.S. (Position, Anchor, Size, and Seal) criteria satisfied . Only 1.4 mm PDL was present. She continued on apixaban 5 mg twice daily and aspirin 81 mg daily post-operatively. Follow-up TEE at 6 weeks demonstrated a trivial PDL measuring 1.9 mm along posterior aspect, with no thrombus seen. At that point, the decision was made to continue aspirin 81 mg daily and clopidogrel 75 mg daily, with discontinuation of apixaban. The patient has not experienced any further episodes of major bleeding, and we are tentatively planning to stop clopidogrel at 6 months post-operatively, with continuation of aspirin 81 mg daily indefinitely thereafter.", "summary": "We present a case of a 79-year-old female patient who underwent LAAO device deployment within a surgically occluded LAA with PDL. She underwent 27 mm LAAO device (WATCHMANTM) deployment and all the P.A.S.S. (Position, Anchor, Size, and Seal) criteria were satisfied. Only 1.4 mm PDL was present. She was continued on apixaban and aspirin post-operatively. Post-operative transoesophageal echocardiogram at 6 weeks demonstrated trivial PDL measuring 1.49 mm. Patient was continued on aspirin and clopidogrel, with discontinuation of apixaban.", "subclaim_evaluations": [ { "subclaim": "The patient was a 79-year-old female.", "support_label": "supported" }, { "subclaim": "The patient underwent LAAO device deployment.", "support_label": "supported" }, { "subclaim": "The LAA was surgically occluded.", "support_label": "not_supported" }, { "subclaim": "The LAAO device was a 27 mm WATCHMANTM.", "support_label": "supported" }, { "subclaim": "The P.A.S.S. criteria were satisfied.", "support_label": "supported" }, { "subclaim": "A 1.4 mm PDL was present.", "support_label": "supported" }, { "subclaim": "The patient was continued on apixaban post-operatively.", "support_label": "supported" }, { "subclaim": "The patient was continued on aspirin post-operatively.", "support_label": "supported" }, { "subclaim": "A post-operative transoesophageal echocardiogram was performed at 6 weeks.", "support_label": "supported" }, { "subclaim": "The 6-week transoesophageal echocardiogram showed trivial PDL measuring 1.49 mm.", "support_label": "not_supported" }, { "subclaim": "The patient was continued on aspirin.", "support_label": "supported" }, { "subclaim": "The patient was continued on clopidogrel.", "support_label": "supported" }, { "subclaim": "Apixaban was discontinued.", "support_label": "supported" } ] }, { "id": "multiclinsum_test_2852_en.txt", "fulltext": "In October 2006, a 46-year-old man received brain MRI, advised by a family doctor to investigate the persistency of memory loss and headaches unresponsive to pain killers medications. MRI evidenced a previously unknown infra- and supra-sellar mass of 3.5 × 2.6 cm, with high pressure on the third ventricle and on the interpenducular cistern; with MRI contrast, peripheral highlighting and an 8 mm enhanced solid nodule were found; the imaging was consistent with a diagnosis of cystic craniopharyngioma .\nSubsequently, the patient underwent fronto-temporal trans-cranial excision of the lesion and histological examination confirmed the diagnosis of PCP. In January 2007, the patient was referred by a multidisciplinary committee for discussion of adjuvant radiotherapy (RT), which was confirmed and then administered (total of 50 Gy in 25 fractions). Follow-up visits with clinical and radiological evaluations were periodically performed until 2013, every 3 months when the patient decided to discontinue medical examinations.\nIn November 2019, for the onset of vertigo and episodes of lipothymia, the patient accessed the emergency department where he performed computed tomography (CT), which showed an iso-dense infra and supra-sellar solid mass of 19 × 23 mm.\nAdditionally, a brain MRI was also performed, which confirmed the presence of a 25 × 38 × 23 mm lesion that extended to the chiasmatic and inter-peduncular cisterns and the flooring of the third ventricle; mass effect had displaced the pituitary gland to the right and had caused compression of the pons .\nThus, a second surgery was indicated for avoiding medical complications. Preliminary endocrinological and ophthalmological evaluations were performed and showed no critical signs. Therefore, in January 2020, the patient underwent total resection of the neoformation via endonasal endoscopic approach and the histological examination confirmed the recurrence of craniopharyngioma. The postoperative course was complicated by polyuria, mental confusion, dysphasia, ptosis, mydriasis, and ophthalmoplegia, and partially improved by palliative treatment with prednisolone and mannitol. Late surgery-related complications were anosmia and psychomotor impairment. At this stage, considering the young age of the patient and the clinical aggressiveness of the tumor, not controlled by curative treatments with surgery and RT, molecular analysis on the surgical sample was carried out: real-time polymerase chain reaction (PCR) for BRAF gene mutation and then next-generation sequencing analysis for a panel of >300 genes was carried out and the canonical mutation V600E in the exon 15 of BRAF gene was identified as the only relevant mutation (c.t1799a, p. V600E). As previously anticipated, the BRAF mutation had been recognized as a characteristic mutation of PCP, being identified in most, but not all, PCP and never in adamantinomatous craniopharyngioma (ACP). Post-operative brain MRI performed in February 2020 revealed residual tissue with dimensions of 19 × 22 × 19 mm, and after contrast, an inhomogeneous increase in this lesion occurred . The timeline of the clinical course is highlighted in .\nDue to the lack of standardized therapeutic approaches, an off-label therapy has been requested, considering BRAF mutation status. In literature, there have been several reports of remarkable responses to BRAF and/or MEK inhibitors (vemurafenib, dabrafenib, and combination therapy) in craniopharyngiomas in various stages, since the discovery that PCPs often harbor BRAF gene mutation .\nThe patient started combination treatment with double inhibition of BRAF and MEK with Dabrafenib 300 mg/day and Trametinib 2 mg/day .\nThe patient was consequently evaluated monthly clinically and with a biochemical profile. The treatment was initially well tolerated with no relevant adverse reactions.\nAt 4 months, laboratory results showed a pathological increase intriglyceride and Cholesterol levels, graded 3 on the CTCAE scale, rarely described during treatment with BRAF/MEK inhibitors. Anti-BRAF and anti-MEK were then suspended temporary and the patient was referred to an endocrinologist: a new medical treatment was established with Fenofibrate and Omega 3 with following the reduction in laboratory levels: oncological treatment was then resumed with dose reduction in accordance to European Medical Agency (EMA) recommendation (Dabrafenib 200 mg/day, Trametinib 1.5 mg/day) when levels reached grade 1, according to CTCAE scale. This was the only adverse event reported by the patient and it did not influence his quality of life. At the time of writing, treatment is ongoing (the total time of treatment until now is 14 months).\nFirst radiological evaluation with MRI after 4 months of treatment showed not only a significant volume reduction of the tumor (14 × 9 × 5 mm vs. 19 × 22 × 19 mm) but also a reduction of the mass effect on the surrounding tissue, for example, realignment of chiasmatic structure . The last radiological evaluation, performed in August 2021 with MRI after 1 year of treatment, showed overall stability of tumor burden compared to November 2020 .", "summary": "A 49-year-old man with recurrent craniopharyngioma, harboring BRAF V600E mutation, has been treated with targeted therapy based on a combination of a BRAF-inhibitor, dabrafenib (150 mg, orally two times daily), and a MEK-inhibitor, trametinib (2 mg, orally two times daily). Before starting treatment, the patient was symptomatic: he lamented confusion, dysphasia, and intense fatigue, that did not allow him to work normally. After just one cycle of treatment, the patient showed an important clinical improvement, reporting a progressive regression of the basal symptoms, hinting at a rapid and dramatic response, which was confirmed at the first radiological assessment. Thus, treatment was continued and at the time of writing, the treatment is still ongoing (total duration of treatment: 14 months) and it is well tolerated, with very good quality of life: the patient has no limitations in daily activities and he has even been able to restart to work.", "subclaim_evaluations": [ { "subclaim": "The patient is a 49-year-old man.", "support_label": "not_supported" }, { "subclaim": "The patient has recurrent craniopharyngioma.", "support_label": "supported" }, { "subclaim": "The tumor harbors a BRAF V600E mutation.", "support_label": "supported" }, { "subclaim": "The patient received targeted therapy.", "support_label": "supported" }, { "subclaim": "The therapy included dabrafenib.", "support_label": "supported" }, { "subclaim": "Dabrafenib was given at 150 mg, orally two times daily.", "support_label": "not_supported" }, { "subclaim": "The therapy included trametinib.", "support_label": "supported" }, { "subclaim": "Trametinib was given at 2 mg, orally two times daily.", "support_label": "not_supported" }, { "subclaim": "Before treatment, the patient had confusion.", "support_label": "supported" }, { "subclaim": "Before treatment, the patient had dysphasia.", "support_label": "not_supported" }, { "subclaim": "Before treatment, the patient had intense fatigue.", "support_label": "not_supported" }, { "subclaim": "After one cycle of treatment, the patient showed clinical improvement.", "support_label": "not_supported" }, { "subclaim": "The patient reported regression of basal symptoms.", "support_label": "not_supported" }, { "subclaim": "The response was confirmed at the first radiological assessment.", "support_label": "supported" }, { "subclaim": "The treatment duration was 14 months.", "support_label": "supported" }, { "subclaim": "The treatment was well tolerated.", "support_label": "supported" }, { "subclaim": "The patient has no limitations in daily activities.", "support_label": "not_supported" }, { "subclaim": "The patient was able to restart work.", "support_label": "not_supported" } ] }, { "id": "multiclinsum_test_1623_en.txt", "fulltext": "A 46-year-old man had been diagnosed with a clear cell carcinoma with rhabdoid differentiation (World Health Organization grade 4) of the left kidney in May 2018 through a renal biopsy. The tumor was locally invasive, associated with metastases to retroperitoneal lymph nodes, the liver and the lungs. Because of the widely metastatic disease, nephrectomy was not performed. At initial diagnosis, the thyroid function tests showed a discrete elevation of his thyroid-stimulating hormone (TSH) at 4.5 mU/L (reference range 0.27-4.2 mU/L), with normal levels of fT4 (16 pmol/L, reference range 12.0–22.0 pmol/L) and fT3 (4 pmol/L, reference range 3.1–6.8 pmol/L) . He was subsequently started on systemic therapy with the tyrosine kinase inhibitor sunitinib in May 2018, pending approval for immunotherapy with nivolumab and ipilimumab. Therapy with nivolumab was initiated in June, and ipilimumab was added in August. The therapy with sunitinib was definitely stopped in October after completion of the mutational analysis of the primary tumor (next-generation 400 gene sequencing panel), which showed mutations in the TERT promoter and the MET gene (exon 15: p.V1088A), and amplification of SETD2 (SET domain containing 2, histone-lysine N-methyltransferase) and MET. Moreover, the tumor showed significant expression of programmed death ligand 1 (80%).\nShortly after the introduction of ipilimumab, he developed transient thyrotoxicosis secondary to immune checkpoint inhibitor-associated thyroiditis, with subsequent hypothyroidism (October 2018: TSH 26.3 mU/L, fT4 9 pmol/L, fT3 2.0 pmol/L). At this stage, levothyroxine substitution was introduced (100 µg/day, corresponding to about 1.3 µg/kg/day). However, the TSH levels further increased to 72.7 mU/L after 4 weeks of therapy. The situation remained unchanged in the following months; in January 2019, the TSH was 81.5 mU/L, the fT4 was decreased at 9 pmol/L, and the fT3 was particularly low at 1.5 pmol/L. On February 18, 2019, the levothyroxine dosage was increased to 300 µg/day (corresponding to 4.3 µg/kg/day). Despite that, the fT4 and fT3 levels remained at similar levels after 2 weeks with 10.4 and 1.1 pmol/L.\nThe patient was hospitalized in March 2019 with a diffuse atopic eczema and was found to be severely anemic. He was hypotensive and tachycardic, and the dermatologic exam revealed dry skin and eczema eruptions with erythematous and squamous papules and plaques.\nAt that time, endocrinology was consulted for the first time. The patient reported profound weakness, a weight loss of 14 kg during the last 8 months, constipation, and a generalized pruritic rash. He plausibly reported regular and appropriate intake of the levothyroxine. Of note, the patient did not present any symptoms of malabsorption. At that time, the patient intermittently took proton pump inhibitors but took no other medication known to interfere with thyroid hormone absorption or metabolism.\nAlthough he then took the levothyroxine under supervision during a week, the thyroid function tests did not improve: fT4 was 8.2 pmol/L, fT3 1.1 pmol/L, total T4 46 nmol/L (reference range 66–181 nmol/L), and total T3 0.5 nmol/L (reference range 1.3–3.1 nmol/L). Suspecting that the patient might have consumptive hypothyroidism, rT3 was ordered and immunohistochemistry of the tumor for D3 expression was planned. The rT3 level drawn 9 days prior to his passing but only available about a month later was found to be elevated at 0.79 nmol/L (reference range 0.14–0.54 nmol/L). Of note, the estimated increase of his tumor burden based on cross-sectional imaging studies was about 57% between June 2018 and March 2019 (557.01 cm3 to 878.73 cm3 based on RECIST (Response Evaluation Criteria in Solid Tumors) criteria).\nThe patient and his family opted for palliative care and he left the hospital; he passed away shortly thereafter at home.", "summary": "A 46-year-old male patient with previously normal thyroid function was diagnosed with a renal carcinoma with rhabdoid differentiation. He was treated with sunitinib, followed by the immune checkpoint inhibitors ipilimumab and nivolumab, and he developed primary hypothyroidism secondary to thyroiditis. Substitution with unusually high doses of levothyroxine as high as 4.3 µg/kg/day did not normalize his thyroid function. Poor compliance was refuted because there was no improvement after observed administration. He had no malabsorption. Although tyrosine kinase inhibitors can increase the expression of D3, this effect tends to be modest. Therefore, the suspicion of tumor-related consumptive hypothyroidism was raised and supported by low free T3 and elevated rT3 levels. The therapy could not be further modified because the patient opted for palliative care and passed away 12 days later. Immunohistochemistry of the tumor from a sample obtained prior to systemic therapy documented abundant expression of D3, corroborating the diagnosis of consumptive hypothyroidism.", "subclaim_evaluations": [ { "subclaim": "The patient is a 46-year-old male.", "support_label": "supported" }, { "subclaim": "The patient had previously normal thyroid function.", "support_label": "supported" }, { "subclaim": "The patient was diagnosed with renal carcinoma with rhabdoid differentiation.", "support_label": "supported" }, { "subclaim": "The patient was treated with sunitinib.", "support_label": "supported" }, { "subclaim": "The patient was treated with ipilimumab.", "support_label": "supported" }, { "subclaim": "The patient was treated with nivolumab.", "support_label": "supported" }, { "subclaim": "The patient developed primary hypothyroidism.", "support_label": "supported" }, { "subclaim": "The hypothyroidism was secondary to thyroiditis.", "support_label": "supported" }, { "subclaim": "Substitution with levothyroxine as high as 4.3 µg/kg/day did not normalize thyroid function.", "support_label": "supported" }, { "subclaim": "The patient had no malabsorption.", "support_label": "supported" }, { "subclaim": "The patient had low free T3 levels.", "support_label": "supported" }, { "subclaim": "The patient had elevated rT3 levels.", "support_label": "supported" }, { "subclaim": "The tumor expressed D3.", "support_label": "not_supported" }, { "subclaim": "The diagnosis of consumptive hypothyroidism was made.", "support_label": "supported" }, { "subclaim": "The patient opted for palliative care.", "support_label": "supported" }, { "subclaim": "The patient passed away 12 days after the diagnosis.", "support_label": "not_supported" } ] }, { "id": "multiclinsum_test_2384_en.txt", "fulltext": "A 53-year-old man with a history of hepatitis B virus infection was admitted to our hospital owing to sudden vision loss in his left eye. On ocular examination, the best-corrected visual acuity was 20/30 in the right eye and hand motion at 60 cm in the left eye. Fundoscopic examination demonstrated near-total rhegmatogenous retinal detachment with breaks at the 4 and 7 o’clock positions in the left eye. The patient underwent placement of an encircling scleral silicone sponge (#506G; MIRA Inc.) and pars plana vitrectomy with silicone oil tamponade An incidental lens contact with posterior capsular damage was noted intraoperatively. Cataract gradually matured and obscured the fundal view; thus, phacoemulsification was performed two weeks later. During the operation, a fragmatome was used through the sclerotomy to remove the dropped lens with suction pressure of 400 mm Hg, flow limit 20 ml/min and an ultrasonic power output of 70% with pulse rate 5 pulse/second. The followability of the lens was poor in silicone oil and lens material was also difficult to be grasped and pulled out. Lens materials were usually pushed into the peripheral vitreous cavity by the fragmatome tip. Because the room lighting and illumination of the microscope were turned off and both the surgeon and the assistant concentrated on the fundal view under the microscope, so change of the eyelid or sclera were ignored. After the dropped nuclear materials were removed and illumination of the microscope and room lighting were turned on, a whitish wound with scorch and tissue defect on the nasal aspect of the left upper eyelid were noted . Examination of the superonasal sclerotomy site, which was created for the passage of fragmatome, also revealed a focal avascular area that resemble the scleral tissue following electro-cauterization. . An area of focal greyish necrosis was noted surrounding the whitish avascular area. Afterwards, the sclerotomy was closed with 7–0 vicryl sutures, and there was no postoperative leakage. We prescribed tobramycin and dexamethasone ointment (Tobradex®, Alcon, Rijksweg, Belgium) twice a day for the suspected thermal wounds on the eyelid and sclera. Because of the posterior capsular tear, the Sensar® 3-piece Intraocular Lens (AR40E, Johnson & Johnson, CA, US) was inserted and placed into the ciliary sulcus. The retina was attached under silicone oil tamponade. After following-up for one month, both eyelid and scleral wounds healed gradually with scar formation . The patient was then lost to follow-up.", "summary": "We present the case of a 53-year-old male patient with a thermal burn wound on the upper eyelid and sclera following phacoemulsification for a dropped lens in a silicone oil-filled vitreous. We further designed an experiment to verify our hypothesis that thermal injury could be induced by the high temperature of the metal tip during phacoemulsification in silicone oil. In our experiment, during 420 s of continuous ultrasonic wave, the temperature of the fragmatome tip in the balanced salt solution (BSS) increased from 22.0 to 24.0 ºC, while the temperature of the fragmatome tip in the silicone oil group increased from 22.0 to 43.0 ºC.", "subclaim_evaluations": [ { "subclaim": "The patient was a 53-year-old male.", "support_label": "supported" }, { "subclaim": "The patient had a thermal burn wound on the upper eyelid.", "support_label": "supported" }, { "subclaim": "The patient had a thermal burn wound on the sclera.", "support_label": "supported" }, { "subclaim": "The injury occurred following phacoemulsification.", "support_label": "supported" }, { "subclaim": "The injury occurred due to a dropped lens.", "support_label": "supported" }, { "subclaim": "The eye was filled with silicone oil.", "support_label": "supported" }, { "subclaim": "An experiment was designed to verify the hypothesis that thermal injury could be induced by the high temperature of the metal tip during phacoemulsification in silicone oil.", "support_label": "not_supported" }, { "subclaim": "During 420 seconds of continuous ultrasonic wave, the temperature of the fragmatome tip in the balanced salt solution increased from 22.0 to 24.0 degrees Celsius.", "support_label": "not_supported" }, { "subclaim": "During 420 seconds of continuous ultrasonic wave, the temperature of the fragmatome tip in the silicone oil group increased from 22.0 to 43.0 degrees Celsius.", "support_label": "not_supported" } ] }, { "id": "multiclinsum_test_2631_en.txt", "fulltext": "Herein, we describe the case of a 73 year-old man in good health, who developed widely disseminated sebaceous carcinoma including metastases to brain, visceral organs, lymph nodes, and bone.\nHe initially presented in late October 2016 for removal of a rapidly growing nodule in the anterior abdominal wall. Two days later he developed confusion, urinary incontinence and progressive aphasia. Emergent magnetic resonance imaging (MRI) of the brain showed 4 enhancing gray-white matter junctional lesions, the two largest measured 3.8 × 3.3 cm in the right frontal lobe and 2.3 × 2.5 cm in the left frontal lobe. Two smaller enhancing lesions in the right parietal lobe measured 8 mm and 4 mm in diameter. In November 2016, he underwent craniotomy and resection of bilateral frontal lobe tumors, and he made a full neurologic recovery and went on to receive post-operative gamma knife radiosurgery to the resection cavities and the small parietal brain lesions .\nHis case was reviewed in melanoma tumor boards at the Masonic Cancer Clinic, University of Minnesota. Sections of tumor revealed sheets of epithelial cells with moderate eosinophilic cytoplasm and areas of tumor infiltrating lymphocytes . Cells exhibited nuclear pleomorphism and increased mitotic activity , desmoplastic stromal reaction and necrosis . Immunohistochemical staining was positive for cytokeratin AE1/AE3 and cytokeratin 7, and negative for S100, HMB45, Melan-A, CD45, calretinin, ERG, p40, TTF1, CDX2, and GATA3. The immunoprofile ruled out melanoma, mesothelioma, lymphoma, sarcoma with epithelioid features, and most visceral carcinomas. Microscopic examination revealed intracytoplasmic lipid vesicles , confirmed by diffuse membranous reactivity for adipophilin [, ] . The findings supported a histopathologic diagnosis of sebaceous carcinoma. Importantly, additional tumor testing confirmed high expression of PD-L1 in 100% of tumor cells . Commercial genomic testing using next-generation sequencing (Foundation Medicine, Massachusetts, USA) confirmed the tumor was microsatellite stable and carried a mutational burden of 17 mutations/Mb. Table also shows various somatic mutations in genes for regulatory transcription factors, DNA repair proteins, growth factor receptors, and targetable MAPK signaling proteins. Several of the affected genes have also been described in cases of sebaceous carcinoma reported in the COSMIC database .\nInitial staging positron emission tomography-computed tomography (PET/CT) revealed evidence of widely disseminated disease involving lung and liver, muscle, bone, and multi-compartment bulky lymphadenopathy in chest and abdomen . Standard chemotherapy approaches using platinum-based chemotherapy were reviewed. However, the patient and family strongly favored a less toxic therapy, considering advanced age and quality of life concerns. Given the strong rationale for use of checkpoint inhibitors in several other tumor types, moderately high tumor mutational burden (17 muts/Mb), and strong PD-L1 expression the patient opted for anti-PD1 immunotherapy. He initiated off-label treatment with pembrolizumab (2 mg/kg, every 3 weeks) in December 2016.\nFollow up PET/ CT scan 3 months after the initiation of anti-PD1 therapy revealed remarkable improvement in lymph nodes, lung, and soft tissue, however, there were multiple new and enlarging hepatic and osseous metastases initially worrisome for progression. After multidisciplinary review, the findings were felt consistent with pseudo-progression and immunotherapy was continued. Restaging PET/ CT obtained after 6 months of treatment showed further significant improvements in all previously noted lesions , with residual FDG activity seen in small mediastinal and abdominal lymph nodes. To further characterize the patient’s innate and adaptive immune status at the time of his near complete response, a flow cytometry study of peripheral blood was performed. Lymphocyte subset analysis showed evidence of circulating CD45RA-CD27+ central memory (CM) and effector memory (EM) T cells, and a population of mature CD16 + CD57+ NK cells .\nHe continued on pembrolizumab, however, after 10 months of therapy he developed severe fatigue and orthostatic hypotension requiring hospitalization. Laboratory testing showed him to have secondary adrenal insufficiency with low (< 0.7 mcg/dL) serum cortisol and low (< 11 pg/mL) ACTH levels. He began 1 mg/kg prednisone with a prolonged steroid taper, and during high dose steroid therapy pembrolizumab dosing was interrupted. In December 2017, with 12 months of follow-up, restaging PET/CT was obtained and showed new FDG avid mediastinal and abdominal lymph nodes and a new hepatic and small bowel lesion . Biopsy of the liver lesion in January 2018 confirmed recurrent metastatic sebaceous carcinoma, and repeat immunohistochemical staining showed tumor cells continued to express high levels of PD-L1 (not shown). After discussion, the patient elected to restart immunotherapy, and he was continued on maintenance adrenal replacement therapy with hydrocortisone (10 mg/5 mg). Recent restaging studies demonstrate growth of the mediastinal metastases and a reduction in the size of the hepatic and small bowel metastases, suggestive of pseudoprogression and a durable ongoing response to pembrolizumab (Additional file ).", "summary": "A 73 year-old man presented with confusion and was found to have widely disseminated sebaceous carcinoma with metastases to brain, lungs, liver, bowel, lymph nodes, and bone. Following initial treatment of the brain metastases with surgery he received post-operative radiosurgery. He then began systemic immunotherapy with pembrolizumab. After 6 months, he developed a near complete response to therapy by irRECIST and RECIST v.1.1. The response was associated with circulating CD8+ T cells with central memory (CM) and effector memory (EM) phenotype and mature CD16 + CD57+ NK cells. During treatment the patient developed adrenal insufficiency requiring high-dose systemic corticosteroids and later adrenal replacement therapy. After 12-months of follow-up he showed imaging evidence of progression in liver, mediastinum, and abdominal lymph nodes. Given persistent, strong PD-L1 expression he resumed pembrolizumab therapy and showed radiographic evidence of an ongoing response to therapy.", "subclaim_evaluations": [ { "subclaim": "The patient is a 73-year-old man.", "support_label": "supported" }, { "subclaim": "He presented with confusion.", "support_label": "supported" }, { "subclaim": "He had widely disseminated sebaceous carcinoma.", "support_label": "supported" }, { "subclaim": "The cancer had metastases to the brain.", "support_label": "supported" }, { "subclaim": "The cancer had metastases to the lungs.", "support_label": "supported" }, { "subclaim": "The cancer had metastases to the liver.", "support_label": "supported" }, { "subclaim": "The cancer had metastases to the bowel.", "support_label": "supported" }, { "subclaim": "The cancer had metastases to the lymph nodes.", "support_label": "supported" }, { "subclaim": "The cancer had metastases to the bone.", "support_label": "supported" }, { "subclaim": "He received surgery for brain metastases.", "support_label": "supported" }, { "subclaim": "He received post-operative radiosurgery.", "support_label": "supported" }, { "subclaim": "He began systemic immunotherapy with pembrolizumab.", "support_label": "supported" }, { "subclaim": "After 6 months, he had a near complete response by irRECIST.", "support_label": "not_supported" }, { "subclaim": "After 6 months, he had a near complete response by RECIST v.1.1.", "support_label": "supported" }, { "subclaim": "The response was associated with circulating CD8+ T cells with central memory phenotype.", "support_label": "not_supported" }, { "subclaim": "The response was associated with circulating CD8+ T cells with effector memory phenotype.", "support_label": "not_supported" }, { "subclaim": "The response was associated with mature CD16+ CD57+ NK cells.", "support_label": "supported" }, { "subclaim": "He developed adrenal insufficiency.", "support_label": "supported" }, { "subclaim": "He required high-dose systemic corticosteroids.", "support_label": "supported" }, { "subclaim": "He later received adrenal replacement therapy.", "support_label": "supported" }, { "subclaim": "After 12 months, imaging showed progression in the liver.", "support_label": "supported" }, { "subclaim": "After 12 months, imaging showed progression in the mediastinum.", "support_label": "supported" }, { "subclaim": "After 12 months, imaging showed progression in abdominal lymph nodes.", "support_label": "supported" }, { "subclaim": "He had persistent, strong PD-L1 expression.", "support_label": "supported" }, { "subclaim": "He resumed pembrolizumab therapy.", "support_label": "supported" }, { "subclaim": "He showed radiographic evidence of an ongoing response to therapy.", "support_label": "supported" } ] }, { "id": "multiclinsum_test_2586_en.txt", "fulltext": "A 48-year-old Japanese male was treated for uveitis of unknown aetiology in the left eye at a general ophthalmology clinic. Prednisolone (PSL) 40 mg/day was started due to the development of macula oedema (ME) in his left eye. Although ME improved temporarily, tapering of PSL to 20 mg/day resulted in relapse of ME. He then complained of blurred vision in the left eye due to recurrence of intraocular inflammation and was referred by the local ophthalmologist to Department of Ophthalmology, Tokyo Medical University Hospital. He has no medical history. At presentation at our facility, best-corrected visual acuity (BCVA) was 20/12.5 in the right and 24/20 in the left eye, and intraocular pressure was normal. Slit-lamp examination revealed 1 + cells in anterior chamber in left eye; fundus photographs showed diffuse vitreous haze and mild exudates in peripheral retina in left eye; fluorescent angiography depicted significant retinal vasculitis characteristic of Bechet’s disease at the posterior pole and periphery retina in left eye; and OCT confirmed ME in left eye . Peripheral blood test showed elevated white blood cell count, elevated percent neutrophils, elevated LDH, positive for HLA-A26, negative for HLA- B51, negative tuberculin skin test (TST) and negative T-SPOT.TB test . He was diagnosed with incomplete type of Bechet disease based on the ophthalmological findings, recurrent oral ulcer, erythema nodosum-like rash in his legs, and HLA-A26 positivity. After a screening test, ADA was started as steroid-sparing therapy. Following the initiation of ADA, ME improved gradually and tapering of PSL to 2 mg/day was achieved, resulting in favourable outcome.\nHowever, 8 months after starting ADA, the patient developed general malaise. Peripheral blood examination was positive for T-SPOT.TB at this time, and chest X-ray and computed tomography (CT) showed granular shadows in bilateral lungs . He was diagnosed with miliary TB by a respiratory physician. ADA and PSL were discontinued immediately, and 4-drug regimen for miliary TB consisting of isoniazid (300 mg/day), rifampicin (450 mg/day), ethambutol (750 mg/day) and pyrazinamide (dose titrated from 0.8 g/day to 1.5 g/day) was started. The TB treatment was completed 6 months later based on clinical improvement , although T-SPOT.TB was still positive. During the period when ADA was discontinued, the patient received adjunctive therapy with betamethasone eye drops and sub-Tenon's injection of triamcinolone acetonide to manage the condition. However, the efficacy of these treatments approach was limited to control ME , resulting in decreased BCVA in the left eye (10/20) and gradual elevation of intraocular pressure due to topical administration of steroid. Therefore, a decision was made to restart TNF inhibitor. Although miliary TB treatment had been completed, the patient still tested positive for T-SPOT.TB, necessitating initiation of infliximab (IFX) in combination with isoniazid (300 mg/day) to address the condition. Following the initiation of IFX, subsequent fluorescein angiography demonstrated more severe vascular leakage compared to the initial examination. However, improvements of ME, vitreous opacity and BCVA in the left eye (24/20) were observed. Furthermore, there was no TB relapse during the course of treatment after starting IFX for 3 years.", "summary": "A 48-year-old Japanese male was treated for uveitis of unknown aetiology in the left eye at a general ophthalmology clinic. He was referred to Department of Ophthalmology, Tokyo Medical University Hospital because of macula oedema (ME) not responding to prednisolone (PSL) 20 mg. BD was diagnosed based on fluorescein angiographic findings of diffuse retinal vasculitis characteristic of BD, recurrent oral aphthous ulcer, erythema nodosum-like rash in his legs, and HLA-A26 positivity. After a screening test, adalimumab (ADA) was started as steroid-sparing therapy. Eight months after starting ADA, the patient was diagnosed with miliary TB. ADA and PSL were discontinued immediately due to TB. Anti-TB treatment was completed after 6 months based on clinical improvement, although T-SPOT.TB was still positive. Infliximab with isoniazid was started due to relapse of ME, worsened vitreous haze, and worsened visual acuity in his left eye. Subsequently, his ocular symptoms subsided and there was no relapse of TB.", "subclaim_evaluations": [ { "subclaim": "The patient is a 48-year-old Japanese male.", "support_label": "supported" }, { "subclaim": "He was treated for uveitis of unknown aetiology in the left eye.", "support_label": "supported" }, { "subclaim": "He was referred to Tokyo Medical University Hospital.", "support_label": "supported" }, { "subclaim": "He had macula oedema not responding to prednisolone 20 mg.", "support_label": "supported" }, { "subclaim": "Behçet's disease was diagnosed based on clinical findings.", "support_label": "supported" }, { "subclaim": "The diagnosis included diffuse retinal vasculitis characteristic of Behçet's disease.", "support_label": "supported" }, { "subclaim": "He had recurrent oral aphthous ulcers.", "support_label": "supported" }, { "subclaim": "He had erythema nodosum-like rash in his legs.", "support_label": "supported" }, { "subclaim": "He was HLA-A26 positive.", "support_label": "supported" }, { "subclaim": "Adalimumab was started as steroid-sparing therapy.", "support_label": "supported" }, { "subclaim": "Eight months after starting adalimumab, the patient was diagnosed with miliary TB.", "support_label": "supported" }, { "subclaim": "Adalimumab and prednisolone were discontinued due to TB.", "support_label": "supported" }, { "subclaim": "Anti-TB treatment was completed after 6 months.", "support_label": "supported" }, { "subclaim": "T-SPOT.TB was still positive after completing anti-TB treatment.", "support_label": "supported" }, { "subclaim": "Infliximab with isoniazid was started due to relapse of macula oedema.", "support_label": "supported" }, { "subclaim": "The patient had worsened vitreous haze.", "support_label": "supported" }, { "subclaim": "The patient had worsened visual acuity in his left eye.", "support_label": "supported" }, { "subclaim": "Ocular symptoms subsided after starting infliximab.", "support_label": "supported" }, { "subclaim": "There was no relapse of TB.", "support_label": "supported" } ] }, { "id": "multiclinsum_test_747_en.txt", "fulltext": "A 55-year-old Caucasian male presented in February 2005 with new onset hematuria, easy bruising, and jaundice. He also reported fevers, nausea with vomiting and fatigue in the week prior to presentation without any associated abdominal pain or pruritus. At presentation, he was afebrile and there was no skin rash, hepatosplenomegaly, asterixis, or stigmata of chronic liver disease but he was deeply jaundiced with scleral icterus and multiple ecchymoses. Initial laboratory tests included a white blood cell count of 13.7 (4.0–10.0 K/UL) with a left shift, hemoglobin 15.5 (13.5–17.5 GM/DL), platelets 200 (140–450 K/UL), AST 1466 (20–57 IU/L), ALT 1459 (21–72 IU/L), total bilirubin 5.3 (0.0–1.5 mg/dl), direct bilirubin 4.9 (0.0–0.8 mg/dl), alkaline phosphatase 219 (30–136 IU/L), INR 13, and prothrombin time 145.8 (10.0–13.5 sec). Serum liver biochemistries were normal 4 months prior (AST 32 IU/L, ALT 40 IU/L, Total Bilirubin 0.5 mg/dl). An abdominopelvic CT scan without contrast was unremarkable.\nThe patient had a history of mild depression, hypertension, and hyperlipidemia. He denied using intravenous drugs or recent travel or sick contacts. He had discontinued alcohol in 2002 but smoked a half-pack of cigarettes for the past 8 years. He was receiving warfarin for a prosthetic mitral valve since 2002 and had a previously stable and therapeutic INR. His other medications for the past 3 years included metoprolol XL, atorvastatin, and aspirin. Paroxetine had been started shortly after surgery and discontinued in May 2004 but restarted in October 2004 for recurrent depressive symptoms. Bupropion 150 mg bid was started for smoking cessation in July 2004 and was continued up until hospitalization (6 months of treatment). The patient reported never having received bupropion or other anti-depressants beyond the paroxetine previously. He also denied ingesting over the counter products such as acetaminophen or herbals. He had allergies to penicillin and sulfa drugs that caused hives.\nAfter receiving several units of fresh frozen plasma, he was temporarily placed on intravenous heparin. Diagnostic studies included a serum iron of 193 ug/dl, transferrin saturation of 55%, and ferritin of 974 mg/dl but subsequent hemochromatosis genotyping was negative. Serum ceruloplasmin was normal at 28 mg/dl. Serological studies for acute hepatitis A IgM, hepatitis B surface antigen and anti-HB core antibody, and hepatitis C RNA by PCR as well as CMV and EBV serologies were negative. However, an anti-nuclear antibody (ANA titer = 1:160; speckled pattern) and anti-smooth muscle antibody (ASMA titer = 1:40) were positive. A surface echocardiogram revealed an ejection fraction of 75–80%. Despite withdrawal of all outpatient medications, his serum aminotransferases and bilirubin continued to rise . A transjugular liver biopsy revealed severe interface hepatitis with intense peri-portal inflammatory infiltrate consisting of a mixture of lymphocytes, eosinophils, and a few scattered plasma cells . A reticulin stain showed hepatic collapse with crowding of the reticulin meshwork and loss of hepatocytes. A trichrome stain did not reveal established fibrosis. A pathological diagnosis of a severe hepatotoxic injury due to a drug with autoimmune-like features was made.\nBecause of the persistent severe biochemical injury, the patient was started on prednisone 60 mg/day. Over the next 13 days, the serum ALT levels trended down . His total bilirubin peaked at 22.7 mg/dl and his ALT reached a second peak at 1357 IU/L before trending down over the next four weeks. The patient's INR remained difficult to manage even with lower doses of coumadin, ranging between 1.6 and 3.7. However, the INR values became more stable at approximately 20 days after institution of prednisone therapy. Upon referral to the University of Michigan, a repeat ANA was higher at 1:1280 and serum IgG, IgM, and IgA levels were 1510 mg/dl, 125 mg/dl, and 367 mg/dl, respectively. At this point, the patient felt much improved and his prednisone was tapered off over 6 weeks. The patient was discharged on prednisone, metoprolol and coumadin. Three weeks later his transaminases began to rise but his bilirubin remained unchanged. Repeat testing two weeks later showed marked elevation of his total bilirubin to 23.7 mg/dl and ALT to 961 IU/L and he was readmitted to the hospital for a possible repeat liver biopsy. A decision was made to forego the liver biopsy and restart the patient on prednisone 60 mg per day and he was discharged home. However, two days later his total bilirubin increased to 37.4 mg/dl and his ALT was 1158 IU/L. He was then admitted to the hospital for liver transplantation evaluation with new onset mental status changes. The patient was started on broad-spectrum antibiotics. The patient's condition quickly deteriorated with the onset of encephalopathy and coagulopathy. On hospital day 13, he developed respiratory failure and was transferred to the ICU but he died of multiorgan failure the next day. An autopsy revealed coronary artery disease but otherwise intact myocardium. His liver was shrunken and weighed 1320 grams and there was evidence of extensive necrosis, predominantly central zone, with cholestasis. He also had bilateral aspergillus pneumonia, which had previously not been recognized. There was no evidence of other solid organ infection. His death was attributed to sepsis resulting from acute liver failure.", "summary": "We present the case of a 55-year old man who presented with jaundice and severe hepatic injury approximately 6 months after starting bupropion for smoking cessation. Laboratory evaluation demonstrated a mixed picture of hepatocellular injury and cholestasis. Liver biopsy demonstrated findings consistent with severe hepatotoxic injury due to drug induced liver injury. Laboratory testing was also notable for positive autoimmune markers. The patient initially had clinical improvement with steroid therapy but eventually died of infectious complications.", "subclaim_evaluations": [ { "subclaim": "The patient was a 55-year-old man.", "support_label": "supported" }, { "subclaim": "The patient developed jaundice.", "support_label": "supported" }, { "subclaim": "The patient had severe hepatic injury.", "support_label": "supported" }, { "subclaim": "The hepatic injury occurred approximately 6 months after starting bupropion.", "support_label": "supported" }, { "subclaim": "Bupropion was prescribed for smoking cessation.", "support_label": "supported" }, { "subclaim": "Laboratory evaluation showed a mixed picture of hepatocellular injury and cholestasis.", "support_label": "supported" }, { "subclaim": "Liver biopsy showed findings consistent with severe hepatotoxic injury.", "support_label": "supported" }, { "subclaim": "The injury was due to drug-induced liver injury.", "support_label": "supported" }, { "subclaim": "Laboratory testing was notable for positive autoimmune markers.", "support_label": "supported" }, { "subclaim": "The patient initially had clinical improvement with steroid therapy.", "support_label": "supported" }, { "subclaim": "The patient eventually died of infectious complications.", "support_label": "supported" } ] }, { "id": "multiclinsum_test_2264_en.txt", "fulltext": "A 25-years-old severe morbidly obese male (Body Mass Index [BMI] 54 kg/m2, Body Surface Area [BSA] 3.27m2) with no other known past medical history, presented to the emergency department with worsening respiratory distress. Patient’s family denied vaping, electronic cigarette or illicit drug use. On initial evaluation, he was found to have an arterial partial pressure of oxygen (PaO2) of 28 mmHg and an arterial partial pressure of carbon dioxide (PaCO2) of 79 mmHg, non-responding to supplemental oxygen and non-invasive positive pressure ventilation. He was endotracheally intubated, placed on lung protective mechanical ventilation with a fraction of inspired oxygen [FiO2] of 100%, and admitted to the intensive care unit (ICU). Initial respiratory viral panel, blood and respiratory cultures were negative. Chest radiograph demonstrated bilateral pulmonary infiltrates.\nInitial attempts to evaluate heart function with transthoracic echocardiography were unsuccessful given the patient’s body habitus. Over the following five days, efforts to decrease the fraction inspired on oxygen (FiO2) were unsuccessful (nadir of 80%), and his PaO2/FiO2 ratio ranged around 110-164 mmHg. Pulmonary compliance was still preserved at this point. Next day, the patient developed frank anuria and acute kidney failure, requiring initiation of continuous veno-venous hemodialysis (CVVHD). Transesophageal Echocardiogram (TEE) revealed a mildly dilated left ventricle with moderately reduced function (ejection fraction 30–35%), no signs of wall motion abnormalities, and a moderate-to-severe dilated right ventricle with elevated systolic pressures (50–60 mmHg) .\nThe patient hypoxemia worsened (PaO2/FiO2 ratio of 75 mmHg) with associated ventilator desynchrony and worsening pulmonary compliance (plateau pressures 39cmH2O) for which neuromuscular blockade was started. A pulmonary artery catheterization demonstrated elevated pulmonary artery pressures (systolic 58 mmHg, diastolic 32 mmHg, mean 41 mmHg) and a central venous pressure of 14 mmHg. Inotropic support (milrinone) and inhaled epoprostenol were started, all aimed to decrease the pulmonary artery pressures and enhance right ventricular function. In spite of these changes, the patient still remained severely hypoxemic (PaO2 64 mmHg) as well as hypercarbic and acidotic (79 mmHg, pH 7.22, respectively) with normal lactate levels (1.7 mmol/L, normal value < 2 mmol/L), as well as normotensive with no vasopressor requirement.\nGiven that conservative therapy for acute respiratory distress syndrome (ARDS) failed, the decision was to institute extracorporeal membrane oxygenation (ECMO). Since no obvious signs of low cardiac output were present, the decision was made to institute veno-venous (VV) ECMO, via a 25-French multi-orifice left femoral vein drainage cannula with its tip at the left iliac vein, and a 21-French right internal jugular vein return cannula with its tip at the right atrium, reaching flows of 5–6 l/minute . The patient was initially placed on sweep flow rate of 10 l/minute and FiO2 100% (PaO2 344 mmHg). The prior hemodialysis catheter was left for administration of medications and blood products, and the CVVHD was run through the VV-ECMO circuit. The patient was continued on lung protective ventilation with tidal volumes at 6 ml/kg (ideal body weight), PEEP 10cmH20 and FiO2 100% and the inhaled epoprostenol therapy was discontinued.\nThree days later, the patient severe hypoxemia persists notwithstanding VV-ECMO at maximum settings (nadir PaO2 52 mmHg, arterial O2 saturation 81%). Oxygenator issues were ruled out by excluding any obvious thrombus in circuit and by confirming post-oxygenator high oxygenation levels (post-ECMO PaO2 332 mmHg). Nitric oxygen (NO) therapy was initiated to assist with right ventricular and pulmonary artery pressure off-loading. A supplementary 21-French drainage cannula was placed in the right femoral vein and its tip at the junction of the inferior vena cava and the right atrium , achieving flows of 7–8 L/min (veno-veno-venous [VV-V] ECMO). The patient oxygenation status intermittently improved (PaO2 310 mmHg), although a significantly elevated lactate dehydrogenase (LDH) was noticed (> 12,500 unit/L; normal range 313–618 units/L). Liver function panel was normal.\nOn next day, hypoxemia persists (PaO2 66 mmHg), with associated systemic hypotension (mean arterial pressure [MAP] of 52 mmHg) and signs of worsening tissue oxygenation (serum lactic acid 5.5 mmol/L). The team decided to switch to VV and VA ECMO with parallel circuits, in order to provide further cardiovascular support, relieve the patient’s refractory hypoxemia and provide adequate flows for his BSA.\nThe original VV-ECMO circuit consisting of a left femoral vein drainage cannula and right internal jugular vein return cannula was continued, and VA-ECMO was instituted through the existing venous cannula in the right femoral vein (which became the drainage cannula) and an additional 17-French right femoral artery return cannula with its tip at the distal aorta before its bifurcation . Distal right lower limb infusion cannula was placed to the right superficial femoral artery. No significant drop in the venous pressures in the original VV-ECMO or in the CVVHD lines was noticed when the four cannulations were instituted. The total flow of both circuits was 10–11 L/min: 5-6 L/min for the VV-ECMO and 5 L/min for the VA-ECMO.\nThe patient’s hemodynamics and oxygenation subsequently improved over the course of the next days (average MAP 68 mmHg, average PaO2 170 mmHg). A significant decrease in the LDH levels was noticed. No clinical or laboratory signs of upper body hypoxia (Harlequin Syndrome) was noticed. Adequate weaning of flow sweeps and FiO2 in both circuits was achieved. VV-ECMO was removed by hospital day #29. TEE demonstrated an improved left ventricular function (ejection fraction 45%) with persistent right ventricular dilation, for which the VA-ECMO was continued to provide further relief of the right ventricle and successfully removed 5 days later. The patient continued further ventilator weaning and planned for long-term acute care recovery.", "summary": "We present the case of a 25-year-old morbidly obese male patient admitted for severe acute respiratory distress syndrome (ARDS) and refractory hypoxemia, requiring institution of double cannulation for veno-venous ECMO. Since his hypoxemia persisted, likely due to insufficient flows given his large body surface area, an additional drainage venous cannula was implemented to provide higher flows, temporarily addressing his oxygenation status. Unfortunately, the patient developed concomitant cardiogenic shock refractory to inotropic support and extracorporeal fluid removal, further worsening his oxygenation status, thus the decision was to institute four-cannulation/parallel-circuits veno-venous and veno-arterial ECMO, successfully controlling both refractory hypoxemia and cardiogenic shock.", "subclaim_evaluations": [ { "subclaim": "The patient is a 25-year-old male.", "support_label": "supported" }, { "subclaim": "The patient is morbidly obese.", "support_label": "supported" }, { "subclaim": "The patient was admitted for severe acute respiratory distress syndrome.", "support_label": "supported" }, { "subclaim": "The patient had refractory hypoxemia.", "support_label": "supported" }, { "subclaim": "The patient required double cannulation for veno-venous ECMO.", "support_label": "supported" }, { "subclaim": "The patient's hypoxemia persisted.", "support_label": "supported" }, { "subclaim": "An additional drainage venous cannula was implemented.", "support_label": "supported" }, { "subclaim": "The additional cannula provided higher flows.", "support_label": "supported" }, { "subclaim": "The patient developed cardiogenic shock.", "support_label": "not_supported" }, { "subclaim": "The cardiogenic shock was refractory to inotropic support.", "support_label": "not_supported" }, { "subclaim": "The cardiogenic shock was refractory to extracorporeal fluid removal.", "support_label": "not_supported" }, { "subclaim": "The decision was made to institute four-cannulation/parallel-circuits veno-venous and veno-arterial ECMO.", "support_label": "supported" }, { "subclaim": "The four-cannulation ECMO successfully controlled refractory hypoxemia.", "support_label": "supported" }, { "subclaim": "The four-cannulation ECMO successfully controlled cardiogenic shock.", "support_label": "not_supported" } ] }, { "id": "multiclinsum_test_1435_en.txt", "fulltext": "A 36-year-old female with a history of untreated hypertension presented to the emergency department with severe headache and a decreased level of consciousness. Computed tomography (CT) of the head demonstrated a large cerebellar parenchymal hemorrhage [Figure , ], but CT angiogram was negative for a vascular malformation, aneurysm, or venous sinus thrombosis. A right frontal EVD was inserted, and the patient underwent suboccipital decompression and clot evacuation, with clinical improvement. Subsequent vascular imaging, including magnetic resonance (MR) and digital subtraction angiography was negative for pathology [Figure –]. A thorough hematological workup was also negative. As such, this was considered a hypertensive hemorrhage.\nFive weeks following admission, the development of communicating hydrocephalus required the insertion of a VP shunt [Figure , ]. Following burr hole placement, the dura was coagulated and monopolar cautery along a forceps was used to puncture the dura and cauterize the pia. After a single pass, good CSF egress was observed, and the ventricular catheter was gently advanced to approximately 10 cm. The surgery was well tolerated and the hydrocephalus and level of consciousness improved.\nOn day 15 following VP shunt insertion, the patient developed a dilated and fixed right pupil. An emergent CT scan demonstrated acute intraparenchymal hemorrhage into the right parietal lobe along the ventriculostomy tract with extensive intraventricular hemorrhage, acute hydrocephalus, and midline shift [Figure , ]. An EVD was inserted through the previous right frontal burr hole, and a CT angiogram followed by a four-vessel angiogram revealed a pseudoaneurysm of a right distal middle cerebral artery (MCA) branch immediately adjacent to the entry point of the ventricular catheter in the right parietal region [Figure –]. A right parietal mini-craniotomy was performed for coagulation of the right distal MCA pseudoaneurysm and removal of the VP shunt. Repeat VP shunt placement was performed 2 months following pseudoaneurysm resection. The patient was discharged to a rehabilitation facility and continued to make cognitive and functional improvement. She has since been discharged home with in-home nursing and physiotherapy assistance.", "summary": "We present the case of a fusiform pseudoaneurysm in a 36-year-old female, which arose from a branch of the middle cerebral artery following VP shunt insertion. Parenchymal and intraventricular hemorrhage at the catheter insertion site developed 15 days postoperatively. The VP shunt was removed, and the aneurysmal segment was coagulated and occluded. Use of a limited dural opening during ventricular catheter placement may have been a factor in pseudoaneurysm formation.", "subclaim_evaluations": [ { "subclaim": "The patient is a 36-year-old female.", "support_label": "supported" }, { "subclaim": "The patient had a fusiform pseudoaneurysm.", "support_label": "not_supported" }, { "subclaim": "The pseudoaneurysm arose from a branch of the middle cerebral artery.", "support_label": "supported" }, { "subclaim": "The pseudoaneurysm developed following VP shunt insertion.", "support_label": "supported" }, { "subclaim": "Parenchymal hemorrhage occurred at the catheter insertion site.", "support_label": "supported" }, { "subclaim": "Intraventricular hemorrhage occurred at the catheter insertion site.", "support_label": "supported" }, { "subclaim": "The hemorrhage occurred 15 days postoperatively.", "support_label": "supported" }, { "subclaim": "The VP shunt was removed.", "support_label": "supported" }, { "subclaim": "The aneurysmal segment was coagulated.", "support_label": "supported" }, { "subclaim": "The aneurysmal segment was occluded.", "support_label": "not_supported" }, { "subclaim": "Use of a limited dural opening during ventricular catheter placement may have been a factor in pseudoaneurysm formation.", "support_label": "not_supported" } ] }, { "id": "multiclinsum_test_1095_en.txt", "fulltext": "A 56-year-old Caucasian male with a past medical history of hypertension, acute coronary syndrome and atrial fibrillation presented to the emergency department (ED) with acute epigastric pain. His complaints had started 2 weeks earlier and had worsened 1 day prior to ED presentation. The pain was associated with nausea and increased on inspiration. Defecation and micturition were normal. In addition to fenprocoumon and sotalol, he was on antihypertensives, a statin and a proton-pump inhibitor. There was no history of trauma. Physical examination showed a pale, sweating and obese man in pain. His blood pressure was 113/73 mmHg, with a heart rate of 72 beats/min, oxygen saturation of 95% on room air and a respiratory rate of 13 breaths/min. The abdomen was not distended, and there were normal bowel sounds. He had epigastric tenderness without muscular defence or hepato-splenomegaly. His initial haemoglobin was 8.5 mmol/l. White blood cell count was 8.5 × 109/l with a c-reactive protein of 26 mg/l. The international normalised ratio (INR) was 2.4. Abdominal ultrasound showed an inhomogeneous aspect of the spleen without free fluid. Contrast-enhanced computed tomography (CT) imaging of the abdomen revealed splenic haemorrhage with subcapsular hematoma .\nAn acute operation was deemed unnecessary because his vital signs remained stable. Oral anticoagulation was reversed with 10 mg vitamin K. The patient was admitted to the hospital for observation and was discharged in good condition after 3 days.", "summary": "A 56-year-old male on oral anticoagulation presented to the emergency department with epigastric pain, nausea, and left upper quadrant tenderness. There was no history of trauma. Contrast-enhanced CT imaging revealed a large subcapsular haematoma of the spleen. Oral anticoagulation was antagonised with vitamin K and the patient was discharged in good condition after 3 days of clinical observation.", "subclaim_evaluations": [ { "subclaim": "The patient is a 56-year-old male.", "support_label": "supported" }, { "subclaim": "The patient was on oral anticoagulation.", "support_label": "supported" }, { "subclaim": "The patient presented with epigastric pain.", "support_label": "supported" }, { "subclaim": "The patient reported nausea.", "support_label": "supported" }, { "subclaim": "The patient had left upper quadrant tenderness.", "support_label": "supported" }, { "subclaim": "There was no history of trauma.", "support_label": "supported" }, { "subclaim": "Contrast-enhanced CT imaging was performed.", "support_label": "supported" }, { "subclaim": "The CT showed a large subcapsular haematoma of the spleen.", "support_label": "supported" }, { "subclaim": "Oral anticoagulation was antagonised with vitamin K.", "support_label": "supported" }, { "subclaim": "The patient was discharged after 3 days of clinical observation.", "support_label": "supported" } ] }, { "id": "multiclinsum_test_3384_en.txt", "fulltext": "Presentation, history, and physical examination on hospital admission\nIn March 2014, a 33-year-old Javanese woman presented with dyspnea and palpitations at rest and during the night. The patient denied any recent weight gain, peripheral edema, headache, chest pain, fever, or any other constitutional symptoms. She had suffered from hypertension since the age of 20 years, which had been treated intermittently.\n\nOn physical examination, she had dyspnea at rest, was alert, but anxious, and her blood pressure was 170/115 mmHg, with a heart rate of 112 beats per minute, and labored respiration at 32 breaths per minute. During her latest hospitalization, peaks of systolic blood pressure were noted of up to 210 mmHg, with elevated jugular venous pressure. Cardiac examination showed both LV and RV enlargement. Cardiac auscultation detected a fixed split S2 with a loud component and a grade 3/6 ejection systolic murmur which was audible at the upper left sternal border and a diastolic gallop that could be heard at the cardiac apex. The patient had bilateral fine crepitation in the lower zones of the lungs. Abdominal examination showed no organomegaly, no palpable mass, and no abdominal bruits. Neurological examination of the lower limbs showed muscular weakness in both legs with a reduced motor power of 3–4/5. The lower limbs showed symmetric palpable pulses, no pedal edema, and no muscular atrophy.\n\nPast medical history and previous investigations\nIn 2002, she had been diagnosed by echocardiography as having an ostium secundum ASD. Hypokalemia was first documented at a regional hospital in 2007 when she suffered from pre-eclampsia during pregnancy. She had been treated with potassium supplements and several antihypertension medications. However, neither satisfactory blood pressure control nor normal serum potassium levels were achieved during follow-up, and the patient began to complain of increasing weakness. The patient reported that among members of her family, only her mother had suffered from hypertension.\n\nIn 2008, the patient had initially sought a specialist endocrine consultation at our hospital when her hypokalemia resulted in disabling generalized muscle weakness and intense muscle cramps. On her admission in 2008, the following studies were performed, which confirmed a diagnosis of primary aldosteronism. The supine morning plasma aldosterone concentration (PAC) and plasma renin activity (PRA) were 56 ng/mL (N≤15 ng/mL) and 0.13 ng/mL/hour (N=0.5–3.3 ng/mL/hour), respectively. The PAC to PRA ratio was calculated as 430.7 ng/dL per ng/mL/hour (N≤30 ng/dL per ng/mL/hour). Ultrasound of the abdomen showed a mass (3.4×2.3×2.1 cm) in the right suprarenal area that was confirmed with computed tomography (CT) to be an adrenal tumor. The patient had been referred for adrenalectomy, but she initially declined surgery and preferred to remain on medication. She was discharged home with a blood pressure of 145/90 mmHg and a serum potassium level of 3.2 mmol/L with the medications that included spironolactone, captopril, amlodipine, bisoprolol, and potassium chloride tablets. The patient became lost to follow-up for six years, until March 2014. During the period between 2008 to 2014, she was admitted twice to two separate hospitals for episodes of heart failure.\n\nInvestigations on current hospital admission\nOn admission of the patient to our hospital in March 2014, preliminary laboratory investigations showed severe hypokalemia (2.2 mmol/L) which was refractory (range, 1.9–2.6 mmol/L) even with repeated potassium supplementation. Urinary potassium excretion was 43 mmol/24 h indicating a renal loss of potassium. The serum magnesium level was normal, while the sodium concentrations were in the high normal limit (143 mmol/L). Serum creatine phosphokinase (CPK) was elevated at 1,257 IU/L, and creatine kinase isoenzyme myocardial band (CKMB) was 221 IU/L. Arterial blood gas analysis showed metabolic alkalosis and ventilation-perfusion mismatch secondary to pulmonary edema. Renal function tests showed normal serum urea and creatinine. Urinalysis showed no proteinuria or myoglobinuria.\n\nChest X-ray showed cardiomegaly, with a cardiothoracic ratio of 74.3%, and right atrial (RA) and RV enlargement with pulmonary edema. The electrocardiogram (ECG) showed sinus tachycardia with a ventricular rate of 112 beats per minute, left axis deviation, LV hypertrophy with strain, and alteration in ventricular repolarization consistent with hypokalemia with nonspecific ST-T segment depression, and flattened T wave with a prominent U wave. Serum potassium level was 2.1 mmol/L.\n\nBased on initial findings, a diagnosis of acutely decompensated heart failure (ADHF) with hypokalemic myopathy was made, and the patient was immediately treated with oxygen therapy, intravenous isosorbide dinitrate, furosemide, and potassium replacement. Then, a conventional heart failure regimen was begun that included a non-selective β-receptor antagonist and α1-receptor antagonist (carvedilol), an angiotensin converting enzyme (ACE) inhibitor (ramipril), a dihydropyridine calcium antagonist (amlodipine), and an aldosterone receptor antagonist (spironolactone). A serum potassium level was maintained of at least >3 mmol/L with parenteral potassium infusion and tablets.\n\nTransthoracic echocardiography was performed and showed concentric hypertrophy of the LV, with an interventricular septal (IVS) thickness of 14 mm (N=6–9 mm); LV posterior wall thickness in end diastole of 17 mm (N=6–11 mm); LV mass of 473.6 g (N=66–150 g); LV mass index of 284.4 g/m2 (N=43–95 g/m2)); and RV wall thickness of 8 mm in diastole (N≤5 mm). There was four-chamber cardiac dilatation, global ventricular hypokinetic and LV systolic dysfunction, with an ejection fraction of 17% (Teichholz method). A large interatrial septum gap was present with a defect size of 2.4×2.7 cm, with a left-to-right shunt confirming the diagnosis of ostium secundum ASD. The RA and the RV were dilated, and the right ventricular systolic pressure (RVSP) of 60 mmHg indicated moderately severe pulmonary arterial hypertension (PAH).\n\nAn abdominal CT scan was performed and compared with the previous scans, and showed an enlarged adrenal mass, from 3.4 cm in diameter in 2008 to approximately 4 cm in diameter in 2014. The tumor was minimally enhanced after contrast injection with low attenuation (+5 Hounsfield units). The absolute washout was calculated as 68%, and the mass was considered as a lipid-poor adenoma.\n\nThe investigations of endocrine function showed that her PAC failed to be suppressed after 120 minutes of captopril 50 mg, and the PAC-to-PRA ratio was still elevated further, which confirmed the diagnosis of primary aldosteronism. Other adrenal hormone levels were within normal limits. The diagnoses made at this time were of a right adrenal adenoma and biochemical diagnosis of primary aldosteronism, with acute heart failure, decreased LV systolic dysfunction, hypertensive heart disease, severe hypokalemia, rhabdomyolysis, left-to-right cardiac shunt due to a secundum ASD with moderate pulmonary hypertension (WHO functional class II). On this hospital admission, adrenalectomy was performed as the patient was willing to undergo surgery, and the blood pressure was adequately controlled before surgery.\n\nSurgical management on current hospital admission\nAfter sufficient pre-operative preparation, the patient underwent open adrenalectomy and exploration of the right adrenal mass via a posterior approach. The resected adrenal gland was a single, well defined and encapsulated yellowish nodule which weighed 27.9 g and measured 4.1×2.6×1.5 cm. Histopathology examination confirmed a diagnosis of a benign adrenocortical adenoma.\n\nPatient follow-up and outpatient management\nThe patient made an uncomplicated recovery post-operatively. Immediately after the removal of the tumor, the PAC was found to be reduced to 8 ng/mL, and the PAC-to-PRA ratio dropped to nearly normal levels. Her serum potassium concentration was normalized without any supplementation. Approximately three days after surgery, the patient remained clinically stable and had adequate blood pressure control with ramipril 5 mg qd. Her postoperative biochemistry showed a serum potassium of 4.1 mmol/L and normal CPK and CKMB. The patient was discharged home and showed stable biochemical findings on follow-up outpatient visits.\n\nRepeated echocardiography in September 2015 demonstrated improvement in the LV and RV size. Her LVEF had improved from 17% at presentation to 56% at 18 months after adrenalectomy. Right cardiac catheterization showed a mean right atrial pressure (RAP) of 10 mm Hg, a pulmonary artery pressure (PAP) of 54/29 mmHg (mean 42 mmHg), pulmonary vascular resistance (PVR) of 597 dyn s/cm5, and a mean pulmonary capillary wedge pressure of 11 mmHg. The pulmonary artery blood flow (Qp) relative to systemic blood flow (Qs) was 3.8 (Qp/Qs >1.5). Given the significant ASD, particularly with a high PAP and PVR, she was referred for an open surgical closure of her ASD. However, she refused to undergo cardiac surgery because of financial constraints. At her last visit to the clinic in December 2015, the patient was still on ramipril 5 mg qd and remained symptom-free with a blood pressure of 130/80 mmHg and normal potassium level. Currently, her degree of heart failure is stable. At the time of writing this case report, surgical closure of the ASD remains to be undertaken.", "summary": "A 33-year-old woman with resistant hypertension and refractory hypokalemia presented with signs and symptoms of heart failure. She had previously been diagnosed having a right adrenal tumor and ostium secundum type ASD. Transthoracic echocardiography confirmed the location of the ASD, with a left-to-right cardiac shunt, moderate to severe tricuspid insufficiency, moderate pulmonary hypertension (60 mm Hg), four chamber dilatation and biventricular hypertrophy. The left ventricular ejection fraction was 17%. Endocrine function tests showed a raised plasma aldosterone concentration (PAC) to plasma renin activity (PRA) ratio, which supported a diagnosis of primary aldosteronism. A captopril suppression test failed to suppress the patient’s PAC, which confirmed the diagnosis. The patient underwent a right adrenalectomy with subsequent normalization of hypokalemia, PAC, and PAC to PRA ratio and her hypertension was managed successfully with monotherapy. Surgical pathology examination of the tumor revealed an adrenocortical adenoma. At follow-up at 18 months, the patient had a normal potassium level, and her cardiac function and ventricular geometries were improved.", "subclaim_evaluations": [ { "subclaim": "The patient is a 33-year-old woman.", "support_label": "supported" }, { "subclaim": "She has resistant hypertension.", "support_label": "supported" }, { "subclaim": "She has refractory hypokalemia.", "support_label": "supported" }, { "subclaim": "She presented with signs and symptoms of heart failure.", "support_label": "supported" }, { "subclaim": "She had previously been diagnosed with a right adrenal tumor.", "support_label": "supported" }, { "subclaim": "She had previously been diagnosed with an ostium secundum type ASD.", "support_label": "supported" }, { "subclaim": "Transthoracic echocardiography confirmed the location of the ASD.", "support_label": "supported" }, { "subclaim": "The echocardiogram showed a left-to-right cardiac shunt.", "support_label": "supported" }, { "subclaim": "The echocardiogram showed moderate to severe tricuspid insufficiency.", "support_label": "not_supported" }, { "subclaim": "The echocardiogram showed moderate pulmonary hypertension.", "support_label": "supported" }, { "subclaim": "The echocardiogram showed four chamber dilatation.", "support_label": "supported" }, { "subclaim": "The echocardiogram showed biventricular hypertrophy.", "support_label": "supported" }, { "subclaim": "The left ventricular ejection fraction was 17%.", "support_label": "supported" }, { "subclaim": "Endocrine function tests showed a raised plasma aldosterone concentration to plasma renin activity ratio.", "support_label": "supported" }, { "subclaim": "The raised PAC to PRA ratio supported a diagnosis of primary aldosteronism.", "support_label": "supported" }, { "subclaim": "A captopril suppression test failed to suppress the patient’s PAC.", "support_label": "supported" }, { "subclaim": "The patient underwent a right adrenalectomy.", "support_label": "supported" }, { "subclaim": "After the adrenalectomy, hypokalemia normalized.", "support_label": "supported" }, { "subclaim": "After the adrenalectomy, PAC normalized.", "support_label": "supported" }, { "subclaim": "After the adrenalectomy, the PAC to PRA ratio normalized.", "support_label": "supported" }, { "subclaim": "Hypertension was managed successfully with monotherapy.", "support_label": "not_supported" }, { "subclaim": "Surgical pathology examination of the tumor revealed an adrenocortical adenoma.", "support_label": "supported" }, { "subclaim": "At 18 months follow-up, the patient had a normal potassium level.", "support_label": "supported" }, { "subclaim": "At 18 months follow-up, cardiac function improved.", "support_label": "supported" }, { "subclaim": "At 18 months follow-up, ventricular geometries improved.", "support_label": "supported" } ] }, { "id": "multiclinsum_test_1220_en.txt", "fulltext": "A 12-year-old boy complained headache for 6 months. MRI revealed a D-shaped mass adjacent to the superior sagittal sinus and falx in the right parietal lobe. The mass was well-circumscribed and dura-based, with a size of 15 × 27 × 22 mm. No necrosis, cysts or hemorrhage was found. MRI also showed isointense with cortex on the T1-weighted imaging and hyperintense on the T2WI sequence, lightly hyperintense on the T2-Flair weighted imaging, but MRI enhanced homogeneously and intensely after intravenous administration of the contrast with gadolinium . The gray matter next to the central gyrus was buckled. Dural tail sign was observed, suggesting a meningioma “en plaque”, but peritumoral edema was indistinct. Computerized tomography perfusion imaging further showed prolonged time to peak and mean transit time, as well as increased relative cerebral blood volume and flow.\nSimpson grade II gross total resection was performed in a right decubitus position. Through a craniotomy of 5.5 × 6.5 cm, we found his dural arteries and veins enlarged abnormally, while the bone flap had no signs of invasion . The tumor was close to the centerline, its anterior edge adhered to the right vein of Trolard, and the right wall of the superior sagittal sinus and falx was invaded. The central sulcus in close to the tumor was located by the somatosensory evoked potential with cortical electrode on the cortex surface, and the epilepsy wave detected by the electroencephalogram was not found during the operation. The lobulated tumor with the size of 3 × 2.5 cm had a clear boundary with many nodules on the surface and adhered to the normal brain tissue, without full arachnoid membrane between the tumor and the brain. The strata externum of the sagittal sinus and falx was removed, and the inner of the sinus was kept intact. The bone flap was returned to the patient. No neurological adverse events occurred during the follow-up.\nKF-PRO serial scanner was used, and pathological assessment was performed using K-Viewer software. Pathologically, the tumor cells manifested nested, sheet-like or whorled aggregates of spindle to epithelioid cells prominently with indistinct cell borders. Mitotic count was less than 1 per 10 high-power fields. Focally, rhabdoid cells were identified, accounting for 10% of the tumor . Rhabdoid morphology was characterized by incomplete differentiation and intercellular adhesion, not accompanied by paranuclear inclusion body. Atypical features including brain invasion, hypercellularity, small cell formation, macronucleoli, sheeting architecture and spontaneous necrosis, were not identified in this tumor. Therefore, the patient was diagnosed as WHO grade I meningioma with focal rhabdoid features. The tumor cells showed diffuse and strong EMA and SSTR2 immunoreactivity. Immunohistochemistry for CD34, S100, STAT6, CK and SOX10 were negative in all tumor cells. Most tumor cells showed diffuse expression for SMARCB1/INI-1. The Ki-67 index was less than 1%.\nTo determine molecular features and seek potential treatments, a next-generation sequencing-based gene panel (Simceredx, Nanjing, China) was used for genomic profiling in primary tumor tissue and matched blood. Except for a novel MAML2-YAP1 fusion break point (5’ MAML2 exon 1 fused to 3’ YAP1 exons 7–9) identified , no other mutations like single nucleotide polymorphism, InDel and copy number variations were detected.", "summary": "We presented a case of 12-year-old boy with meningioma adjacent to the superior sagittal sinus and falx. Simpson grade II gross total resection was performed after diagnosis. Pathologically, he was diagnosed as WHO grade I meningothelial meningioma with rhabdoid features. A next-generation sequencing-based gene panel was performed to determine the molecular features for potential treatment, and a novel MAML2-YAP1 fusion break point was identified.", "subclaim_evaluations": [ { "subclaim": "The patient is a 12-year-old boy.", "support_label": "supported" }, { "subclaim": "The patient had a meningioma adjacent to the superior sagittal sinus.", "support_label": "supported" }, { "subclaim": "The meningioma was adjacent to the falx.", "support_label": "supported" }, { "subclaim": "The patient underwent Simpson grade II gross total resection.", "support_label": "supported" }, { "subclaim": "The resection was performed after diagnosis.", "support_label": "not_supported" }, { "subclaim": "The tumor was diagnosed as WHO grade I meningothelial meningioma.", "support_label": "supported" }, { "subclaim": "The tumor had rhabdoid features.", "support_label": "supported" }, { "subclaim": "A next-generation sequencing-based gene panel was performed.", "support_label": "supported" }, { "subclaim": "The gene panel was used to determine molecular features for potential treatment.", "support_label": "supported" }, { "subclaim": "A novel MAML2-YAP1 fusion break point was identified.", "support_label": "supported" } ] }, { "id": "multiclinsum_test_2783_en.txt", "fulltext": "In a 78-year-old female patient with long history of persistent AF and symptomatic AF recurrences despite multiple previous ablation procedures and persistently isolated pulmonary veins, we performed isolation of the LAA by applying an anterior and a mitral isthmus line. Following a waiting period of 6 weeks post-LAAI and oral anticoagulation with a direct novel oral anticoagulant (Apixaban), we readmitted the patient in order to implant an endocardial LAA occluder device (Watchman; Boston Scientific, Marlborough, MA, USA). A preprocedural transoesophageal echocardiography (TOE) was performed and excluded a left atrial (LA) thrombus. The novel oral anticoagulant was stopped the day of the procedure. Under deep sedation using midazolam, sufentanil, and continuous infusion of propofol, a single transseptal puncture was performed using a regular 8, 5 Fr SL1 transseptal sheath (St. Jude Medical, Inc., St. Paul, MN, USA) after a multi-electrode diagnostic catheter was inserted into the coronary sinus. Intravenous Heparin was administered with a target-activated clotting time (ACT) of 300 s. Angiography of the LAA was performed revealing a ‘chicken-wing’ morphology . The maximal diameter at the landing zone as measured in fluoroscopy and TOE was 30 mm. Accordingly, a 33 mm Watchman device was selected to occlude the LAA. The transseptal sheath was changed over a regular guidewire for the 15 Fr non-steerable Watchman sheath (Boston Scientific, Marlborough, MA, USA), which was gently advanced over the wire into the distal LAA until the according marker was in the predefined landing zone. Suddenly the patient became hypotensive and TOE showed a massive pericardial effusion . Immediate pericardiocentesis was performed, and a 7 Fr pigtail catheter introduced into the pericardial space. The 15 Fr Watchman sheath was immediately withdrawn into the inferior vena cava to avoid potential thrombus formation along the sheath. The ACT was measured with 357 s. A total of 5000 I.E. of protamine was immediately applied resulting in an ACT of 157 s. Aspirated epicardial blood was autotransfused via a right femoral vein access, but despite continuous aspiration the effusion remained unchanged indicating a massive perforation of the distal LAA.\nIn the meantime, the patient was intubated. Suspecting distal LAA perforation as the source of the massive bleeding proximal occlusion of the LAA was desired. Therefore a new transseptal puncture using a 8.5 Fr SL1 sheath (St. Jude Medical, Inc., St. Paul, MN, USA) was performed, and a guidewire was advanced into the LAA. The guidewire went via the distal LAA into the pericardial space proving the distal LAA perforation. Now, the SL1 transseptal sheath was changed over the wire for 12F steerable FlexCath Advance sheath (Medtronic, Inc., Minneapolis, MN, USA) which was advanced to the base of the LAA followed by introduction of a 28 mm cryoballoon (ArcticFront Advance, Medtronic, Inc., Minneapolis, MN, USA). The cryoballoon was gently moved over a guidewire to the base of the LAA and manually inflated using the cryoballoon manual retraction kit (Medtronic, Inc., Minneapolis, MN, USA) . Contrast medium was applied over the Flexcath sheath and demonstrated complete sealing of the LAA . Later the epicardial blood could be completely aspirated resulting in haemodynamic stability of the patient.\nSince emergency open heart surgery in this older patient would have been associated with high peri- and post-operative risk, we decided to attempt epicardial LAA closure applying the Lariat epicardial LAA suture device (Sentreheart, Redwood City, CA, USA). Another anterior epicardial puncture was performed, and the epicardial magnet was introduced via the epicardial Lariat-sheath while the endocardial magnet was advanced over a second transseptal sheath and across the temporarily deflated cryoballon into the LAA. Both magnets connected and the Lariat device was brought into the pericardium and gently advanced over the LAA and over the cryoballoon to the LAA base . After echocardiographic and fluoroscopic verification of the position of the Lariat snare, the snare was closed and the cryoballoon deflated and pulled back into the LA which resulted in complete closure of the LAA . The Lariat suture was tightened one and a second time after a waiting period of 5 min. A final TOE evaluation as well as another contrast injection via the transseptal sheath demonstrated complete LAA occlusion, no further pericardial effusion occurred. All sheaths except a pericardial 7 Fr pigtail catheter were removed and the patient was transferred to ICU for further monitoring. The patient was extubated 2 h after the LAA closure and after exclusion of further epicardial effusion during the next 24 h the pigtail catheter was removed. She was discharged 10 days after the procedure. Three months from discharge the patient had one episode of persistent AF requiring electrical cardioversion, and she had no further pericardial effusion.", "summary": "An endocardial LAA occlusion was attempted but resulted in perforation of the distal LAA and severe pericardial tamponade. To prevent open heart surgery, a cryoballoon was advanced to the base of the LAA and inflation resulted in complete occlusion and stopped further pericardial bleeding. An epicardial LAA suture device was then successfully implanted and completely sealed the LAA. No further pericardial bleeding occurred, and the patient fully recovered.", "subclaim_evaluations": [ { "subclaim": "An endocardial LAA occlusion was attempted.", "support_label": "supported" }, { "subclaim": "The attempt resulted in perforation of the distal LAA.", "support_label": "supported" }, { "subclaim": "The perforation caused severe pericardial tamponade.", "support_label": "supported" }, { "subclaim": "A cryoballoon was advanced to the base of the LAA.", "support_label": "supported" }, { "subclaim": "Cryoballoon inflation resulted in complete occlusion.", "support_label": "supported" }, { "subclaim": "Cryoballoon inflation stopped further pericardial bleeding.", "support_label": "supported" }, { "subclaim": "An epicardial LAA suture device was successfully implanted.", "support_label": "supported" }, { "subclaim": "The suture device completely sealed the LAA.", "support_label": "supported" }, { "subclaim": "No further pericardial bleeding occurred.", "support_label": "supported" }, { "subclaim": "The patient fully recovered.", "support_label": "supported" } ] }, { "id": "multiclinsum_test_1249_en.txt", "fulltext": "A 15-year-old male presented to the emergency department with a 4-hour history of substernal chest pain and reported an episode of syncope lasting a few minutes. He also reported homicidal ideation and audiovisual hallucinations. The patient reported using “Spice”, a synthetic cannabinoid, repeatedly over the last few hours in order to maintain his euphoric mood. He used a vaporizer for consuming “Spice”. The patient was agitated and experienced audiovisual hallucinations instructing him to harm himself and others. He had no prior psychiatric or medical history. He denied drug allergies. Surgical and family history was unremarkable. Social history revealed that the patient was an emancipated minor, smoking a pack of cigarettes per day, drinking 3-5 beers per month, and a regular user of marijuana and synthetic cannabinoids. He also reported smoking crack cocaine once at age of 13. Physical examination revealed normal cranial nerve examination, tachycardia, hyperventilation, and an erythematous lesion resembling a canker sore in the lateral tongue with surrounding erythema. Blood pressure was 137/83 mmHg, temperature was 37.3 ºC, pulse rate was 75 beats per minute, and respiratory rate was 12 breaths per minute. Laboratory testing revealed no electrolyte abnormalities. Electrocardiography (ECG) showed ST segment elevation in leads V1, V2, V3, and V4, non-specific ST, T-wave changes, and T-wave inversion. Erythrocyte sedimentation rate (ESR) was mildly elevated. Cardiac enzymes were 3.2 ng/ml. Echocardiography revealed hypokinetic systolic dysfunction of the left side of the heart. Liver function tests were within normal limits. Aspirin was immediately administered to the patient and he was admitted to the cardiac catheterization lab, where no blockages in the coronary vasculature were seen. He was given a diagnosis of Takotsubo cardiomyopathy, after that catecholamine levels were seen to be elevated and urine drug screen was negative.", "summary": "A case report of an emancipated 15-year-old male experiencing Takotsubo cardiomyopathy after using the synthetic cannabinoid \"Spice\" is presented here.", "subclaim_evaluations": [ { "subclaim": "The patient is an emancipated 15-year-old male.", "support_label": "supported" }, { "subclaim": "The patient experienced Takotsubo cardiomyopathy.", "support_label": "supported" }, { "subclaim": "The patient used the synthetic cannabinoid 'Spice'.", "support_label": "supported" }, { "subclaim": "The case is presented as a case report.", "support_label": "supported" } ] }, { "id": "multiclinsum_test_2840_en.txt", "fulltext": "We present a 43-year-old nonsmoking and nondrinking white male with oral cancer on the left side of the tongue. A biopsy sample taken from the tumor revealed a G2 keratinizing squamous cell carcinoma. On a CT scan performed two months before the operation, the radiologist described a primary tumor measuring 15 × 10 mm with peripheral contrast enhancement and two suspected, probably metastatic lymph nodes on the left side of the neck in groups III and IV, size 17 × 14 mm and 26 × 16 mm, respectively. Distant metastases were ruled out on chest X-ray and abdominal ultrasound. Moreover, anamnesis proved previous lower extremity deep vein thrombosis, but Doppler ultrasound ruled out active disease.\nThe surgical procedure included excision of the left half of the tongue, the floor of the mouth and the sidewall of the throat and bilateral cervical lymph node dissection in groups I-V on the left side and I-III on the right side. The second part of the operation involved reconstruction by using an anterolateral thigh flap. After three days, reoperation was performed due to hemorrhage from the wound after lymphadenectomy. The final histopathology report revealed G2 keratinizing squamous cell carcinoma, stage IVa (pT3 pN2b, AJCC 8th edition). Additional risk factors included perineural invasion of small nerves, an unfavorable pattern of invasion with small islands (the worst pattern of invasion, 4), a closest margin below 1 mm, and five metastatic lymph nodes (of 49 lymph nodes dissected) without extracapsular extension at levels II, IV, V on the left side. The novel prognostic histopathological grading system in oral squamous cell carcinoma based on tumor budding revealed G-2 . There were 102 budding foci detected per 10 high-power fields. Two to four cell-sized nests or single-cell invasion was observed. A multidisciplinary case conference qualified the patient for postoperative radiochemotherapy, but he refused systemic treatment. Given the patient’s decision, radiotherapy alone was recommended. Five-point head, neck and shoulder masks were employed for patient immobilization, and a CT scan (3 mm slice thickness) without intravenous contrast with the patient in the supine position was performed in the planning radiotherapy process. The dose prescription involved the bilateral lymph nodes I-V to a total dose of 50 Gy in 25 fractions, the left side neck in groups II-V to a total dose of 60 Gy in 30 fractions and the tumor bed with bilateral submandibular lymph nodes to a total dose of 66 Gy in 33 fractions . The VMAT (volumetric modulated arc therapy) technique was applied. In the first stage of treatment, three full arcs were used, followed by three arcs lateralized to the left side of the neck in the second stage. In the third stage, two frontal arcs were applied. Radiotherapy was performed by linear accelerators (Clinac 23EX; Varian Medical Systems, Palo Alto, CA, USA) with an energy of 6 MV and maximal dose rate of 600 MU/min. Two weeks after the beginning of radiotherapy, ultrasound of the neck was performed due to a suspected lump in group III on the right side. It revealed a 16 × 9 mm lymph node. Fine-needle aspiration biopsy was performed in the next stage, confirming metastasis of the squamous cell carcinoma. The multidisciplinary case conference urged the application of a single-fraction stereotactic radiosurgery (SRS) boost of 18 Gy to the metastatic lymph node. After 29 days of conventional treatment, a new 5-point mask, a new CT scan without contrast and an MR scan with gadolinium intravenous contrast (both with 1 mm slice thickness) in the supine position were performed in the planned stereotactic boost process. The GTVboost volume was 0.7 cm3. A 3 mm margin was added to the GTVboost to create a PTVboost volume of 3.1cm3. A new treatment plan consisting of four arcs was prepared. Four 6 MV FFF (flattening filter-free) photon beams with a maximal dose rate of 1400 MU/min were utilized. The dose that fully covers target volume was selected as the prescribed isodose level, so that the minimum dose in the target volume was 100% of the prescribed dose and the maximum dose was 108.4%. The angle range of arcs was adapted to the boost localization and was limited to the right and front sides of the patient. The boost was delivered two days after the last fraction of conventional radiotherapy with the same linear accelerator. Overall treatment time totaled 50 days. Figures and show the dose distribution of the SRS boost and the sum of conventional RTH with SRS boost, respectively. Dose analysis of the conventional and stereotactic radiotherapy is presented consecutively in Tables and . During radiotherapy, oral mucositis and moist desquamation (grade 3, CTCAE v5.0) were observed in the irradiated area, which subsided within three months of follow up. Additionally, Staphylococcus aureus and Klebsiella oxytoca were identified from the throat culture in six week of conventional treatment, subsequently treated using antibiotic therapy consistent with the antibiogram (clindamycin, amoxicillin/clavulanate potassium). Blood tests showed grade 1 anemia and leukopenia after 24 and 33 fraction respectively, and normalized seven months after treatment. Three, ten and thirteen months after the end of radiotherapy, CT scans and laryngological examinations did not prove locoregional recurrence. Chest X-ray and abdominal ultrasound did not detect any metastatic changes one year after treatment. Xerostomia G2 was the only symptom of late toxicity fifteen months after radiotherapy.\nAt 17 months of follow-up, the patient reported coughing, suffocation and bloody sputum.\nA CT scan revealed infiltration (64 × 65 × 100 mm) in the 3rd segment of the right lung, encompassing the hilum and central part of the mediastinum. Pathological examination after endoscopic ultrasound-guided fine needle aspiration (EUS-FNA) proved squamous cell carcinoma with moderate PD-L1 membrane expression (< 50%). Acknowledgment of the tumor in the chest as lung cancer or metastatic disease due to oral cancer was difficult; nevertheless, a further aggressive course might suggest a new primary cancer. The patient was qualified for palliative radiotherapy to a total dose of 30 Gy in 10 fractions (VMAT technique, single arc, gantry angle 30.0–210.0 deg) for the tumor in the chest (systemic treatment was contraindicated in terms of performance status—ECOG 2). Three months later, multiple metastases in the mediastinum, right lung, spleen and bones were detected by PET/CT. The most painful osteolitic lesion in the left ischium and femoral head was irradiated in one fraction to 8 Gy (two-dimensional radiotherapy technique, two coaxial opposite beams from AP and PA directions were used). The patient died the next month.", "summary": "Here, we present a case study of a patient with oral cancer who underwent surgery. During adjuvant radiotherapy, a metastatic cervical lymph node was diagnosed based on fine-needle aspiration biopsy. To increase the total dose to the metastatic tumor, a stereotactic radiosurgery boost of 1 × 18 Gy was performed two days after the last fraction of conventional radiotherapy. The early and late tolerance of this treatment were positive. During the 18-month follow-up, locoregional recurrence was not detected. The patient died due to secondary malignancy.", "subclaim_evaluations": [ { "subclaim": "The patient had oral cancer.", "support_label": "supported" }, { "subclaim": "The patient underwent surgery.", "support_label": "supported" }, { "subclaim": "During adjuvant radiotherapy, a metastatic cervical lymph node was diagnosed.", "support_label": "supported" }, { "subclaim": "The diagnosis of the metastatic cervical lymph node was based on fine-needle aspiration biopsy.", "support_label": "supported" }, { "subclaim": "A stereotactic radiosurgery boost of 1 × 18 Gy was performed.", "support_label": "supported" }, { "subclaim": "The stereotactic radiosurgery boost was performed two days after the last fraction of conventional radiotherapy.", "support_label": "supported" }, { "subclaim": "The early tolerance of the treatment was positive.", "support_label": "supported" }, { "subclaim": "The late tolerance of the treatment was positive.", "support_label": "not_supported" }, { "subclaim": "During the 18-month follow-up, locoregional recurrence was not detected.", "support_label": "supported" }, { "subclaim": "The patient died due to secondary malignancy.", "support_label": "not_supported" } ] }, { "id": "multiclinsum_test_3122_en.txt", "fulltext": "A 41-year-old male was referred to our tertiary cardiovascular center for advanced evaluation of HF.\nHe had a history of progressive dyspnea, orthopnea, bilateral leg swelling, and palpitations for 6 months.\nA coronary angiography procedure had been performed 12 months earlier via the left transfemoral access. The initial vital signs recorded included a heart rate of 130 beats per minute, blood pressure of 135/78 mm Hg, respiratory rate of 36 breaths per minute, and oxygen saturation of 88% at room air. Bilateral, severe, pretibial pitting edema and inspiratory rales auscultable at the base of the lungs were the main findings of his physical examination.\nAdditionally, a palpable, continuous thrill at the right lower quadrant of the abdomen was confirmed by auscultation as a grade-5, systolodiastolic murmur over the left iliac artery. An electrocardiogram revealed nothing unusual other than sinus tachycardia. A chest X-ray revealed cardiomegaly, pulmonary arterial (PA) enlargement, and pulmonary congestion consistent with high-output HF. Echocardiography also revealed enlargement in the PAs, right atrium, right ventricle (RV); a D-shaped septum at diastole; severe tricuspid regurgitation; and moderate mitral regurgitation with a normal left ventricle ejection fraction. The estimated PA systolic pressure from the tricuspid regurgitant jet was 55 mm Hg. In addition, a continuous shunt flow from the left common iliac artery (LCIA) to the left common iliac vein (LCIV) was detected on a Doppler examination. Computed tomography (CT) angiography disclosed an enlarged inferior vena cava (IVC), and an AVF between the LCIA and the LCIV. Right and left heart catheterization and coronary angiography was performed in order to both exclude coronary artery disease and to perform further evaluation of the PH. Systolic, diastolic, mean, and wedge PA pressure was measured as 63, 33, 46, and 14 mm Hg, respectively. The Qp/Qs ratio of 2.5 was consistent with hemodynamically significant systemic to pulmonary shunting via a large AVF. The pulmonary vascular resistance (PVR) and systemic vascular resistance (SVR) were 2.7 and 15 Wood U, respectively. The diagnosis was high-output HF with PH due to a peripheral AVF, and it was decided that the shunt would be closed percutaneously.\nUsing the left femoral arterial access, a 6-F right Judkins catheter was engaged at the site of the AVF, and a 0.035-mm hydrophilic guidewire was crossed over the defect and advanced to the IVC. A snare was advanced from the right femoral vein to the IVC, and following the capture and retrieval of the guidewire, a veno-arterial (VA) loop was created between the right femoral vein and the left femoral artery systems. The delivery sheath of the occluder was pushed forward through this VA loop to the LCIA. Initial attempts to use a 16-mm Amplatzer patent ductus arteriosus (PDA) occluder device (St. Jude Medical, Inc., St. Paul, MN, USA) to close the AVF failed to close the shunt. The use of an Amplatzer atrial septal defect (ASD) occluder (St. Jude Medical, Inc., St. Paul, MN, USA) also failed as a result of malorientation of the device within the LCIA. Finally, shunt closure was achieved with the original 16-mm Amplatzer PDA occluder device in another effort. The signs and symptoms of AVF and high-output HF were markedly relieved immediately after device implantation. A 90th-day control CT and conventional angiography confirmed the stability of device without any significant leakage or luminal narrowing in the LCIA. The invasively evaluated mean PA pressure was determined to be 30 mm Hg, the PVR was 3.1 Wood U, and the Qp/Qs ratio was almost 1.0. Due to the borderline PVR measures, pulmonary arterial hypertension-targeted treatment with bosentan 62.5 mg twice daily followed by 125 mg twice daily was initiated to be accompanied by periodic follow-up. His initial clinical, echocardiographic, hemodynamic, and neurohormonal measurements showed marked and progressive improvement after the procedure.", "summary": "Presently described is the case of a 41-year-old male patient with signs of high-output right heart failure (HF) due to a possibly iatrogenic arteriovenous fistula (AVF) between the left common iliac artery and the left common iliac vein. Invasively evaluated hemodynamic measurements were consistent with severe shunting, which resulted in precapillary pulmonary hypertension (PH). The AVF was successfully closed with a non-dedicated, 16-mm Amplatzer patent ductus arteriosus occluder (St. Jude Medical, Inc., St. Paul, MN, USA). Although his signs and symptoms were documented to be dramatically improved after closure, because mild PH persisted, adjuvant pulmonary arterial hypertension-targeted treatment with bosentan was initiated to prevent late pulmonary vascular disease.", "subclaim_evaluations": [ { "subclaim": "The patient is a 41-year-old male.", "support_label": "supported" }, { "subclaim": "The patient had signs of high-output right heart failure.", "support_label": "supported" }, { "subclaim": "The cause of the heart failure was a possibly iatrogenic arteriovenous fistula.", "support_label": "supported" }, { "subclaim": "The fistula was between the left common iliac artery and the left common iliac vein.", "support_label": "supported" }, { "subclaim": "Invasive hemodynamic measurements showed severe shunting.", "support_label": "supported" }, { "subclaim": "The shunting resulted in precapillary pulmonary hypertension.", "support_label": "supported" }, { "subclaim": "The AVF was closed with a 16-mm Amplatzer patent ductus arteriosus occluder.", "support_label": "supported" }, { "subclaim": "The occluder was provided by St. Jude Medical, Inc.", "support_label": "supported" }, { "subclaim": "The patient's signs and symptoms were dramatically improved after closure.", "support_label": "supported" }, { "subclaim": "Mild pulmonary hypertension persisted after closure.", "support_label": "supported" }, { "subclaim": "Bosentan was initiated as adjuvant pulmonary arterial hypertension-targeted treatment.", "support_label": "supported" }, { "subclaim": "The treatment was started to prevent late pulmonary vascular disease.", "support_label": "not_supported" } ] }, { "id": "multiclinsum_test_2176_en.txt", "fulltext": "A 27-week four days old preterm male infant was born from a dichorionic diamniotic twin pregnancy with low birth weight(1135 gr). His prenatal examinations were completed regularly without reported complications. In the 27th week of pregnancy, the mother experienced premature membrane rupture, contractions, and bleeding. She was treated with antenatal steroids and cesarean delivery was planned due to an arrested birth. During birth, the neonate was hypotonic and apneic, requiring intubation one minute after birth due to respiratory failure with an uncuffed endotracheal tube. His APGAR scores were 4,6 and 7 in the 1st, 5th, and 10th seconds, respectively. He was transferred to the newborn intensive care unit(NICU) for further management. After a diagnosis of respiratory distress syndrome was made, treatment with endotracheal poractant alfa 200 mg/kg, parenteral ampicillin-gentamicin, and caffeine citrate was initiated. His ventilation settings were arranged to assist control and volume guaranteed mode with maximum inspiring pressure of 20 cm/H²O. His cranial ultrasound showed no abnormalities.\nOn hospital day 3, he was extubated to nasal intermittent positive pressure ventilation but required reintubation for recurrent respiratory failure. His antibiotics were escalated to vancomycin-meropenem due to clinical deterioration.\nDuring hospital day 5, the baby had worsening acute hypoxic respiratory failure. A chest x-ray revealed mediastinal pneumothorax , with a follow-up x-ray one hour later showing accelerated pneumothorax on the left side and mediastinal shift to the right. To treat the pneumothorax, a thorax tube was placed through the left 5th intercostal space. Repeat x-rays showed an expanded lung on the left side and air bronchograms on the right. Ten hours later, he had persistent acidosis and hypoxia, with another x-ray displaying a repeat pneumothorax on the left side. The thorax tube was set to continuous suction, resulting in a reduction of pneumothorax on subsequent imaging.\nOn the 6th day of hospitalization, an echocardiogram revealed a 3 mm patent ductus arteriosus(PDA) with mostly left to right two-way shunts and pulmonary hypertension. His oxygen saturation levels were approximately 80%, and his arm-leg saturation differences were higher than 15 mm Hg, suggesting differential cyanosis. These findings were suspicious for persistent fetal circulation; therefore, pediatric cardiology advised against the closure of PDA. A new chest x-ray showed a collapsed left lung, and a second chest tube was placed in the left hemithorax.\nThe decision to perform a surgical intervention was made given no resolution of the pneumothorax after the second chest tube and the patient’s continued clinical deterioration. A left posterolateral thoracotomy was performed. During the exploration, a 1 cm perforated area between the left bronchus and carina was found by following the air leak through the visceral pleura. The perforated area was repaired by using a pleural patch, and suturing with 6.0 prolene was performed. At the end of the procedure, there was no visible bleeding or air leak. The anesthesiologist applied high-pressure air via the endotracheal tube to check for any air leaks. A chest tube was inserted, and the thoracotomy incision was closed by layers. Post-procedure chest x-ray showed an expanded left lung. Three days later, the neonate experienced another episode of hypoxia, which was found to be secondary to a repeat left-sided pneumothorax. Consequently, a second thoracotomy was performed using the same technique as the prior surgery, with an air leak emanating from the same area. The perforated area was repaired using a pleural patch and the left 5th intercostal muscle long peduncle . Fibrin glue and spongestan were used as anchorage on top of the patch . After the repair, no leak was found with the use of maximal airway pressure. A PDA ligation operation was also performed simultaneously during the procedure . There was no air leakage in the repeat x-ray. Both the first and second thorax tubes were removed on postoperative days 0 and 5, respectively. There were no signs of air buildup or pneumothorax on the following days. On the 161st day of admission, the patient was discharged home with a home-type ventilator and 30% oxygen support.", "summary": "In this case, we present a preterm newborn who developed pneumomediastinum and pneumothorax. The pneumothorax persisted, despite placement of a thorax tube, requiring a thoracotomy to detect and treat the bronchial rupture.", "subclaim_evaluations": [ { "subclaim": "The patient was a preterm newborn.", "support_label": "supported" }, { "subclaim": "The patient developed pneumomediastinum.", "support_label": "supported" }, { "subclaim": "The patient developed pneumothorax.", "support_label": "supported" }, { "subclaim": "A thorax tube was placed.", "support_label": "supported" }, { "subclaim": "The pneumothorax persisted despite placement of a thorax tube.", "support_label": "supported" }, { "subclaim": "A thoracotomy was performed.", "support_label": "supported" }, { "subclaim": "A bronchial rupture was detected.", "support_label": "supported" }, { "subclaim": "The bronchial rupture was treated.", "support_label": "supported" } ] }, { "id": "multiclinsum_test_14_en.txt", "fulltext": "The proband, female of 1 year and 3 months old, was referred to the Research Centre for Medical Genetics because of severe failure to thrive. She was born from a first pregnancy. Parents were nonconsanguineous and had normal growth. The threat of miscarriage took place at 27 weeks. Delivery was emergent at 38 weeks and 5 days by cesarean section. The condition at birth was severe. Respiratory failure was increasing. The child was on a ventilator for five days. In total, respiratory support was required for five months. The patient was diagnosed with pulmonary hypertension.\nBody weight at birth was 1490 g (Z-score −4.50), 40 cm in length (Z-score −4.54). Head circumference was 32.5 cm (Z-score −2.59). Chest circumference was 24 cm. She had hydrocephalic head, short palpebral fissures, ocular and nipple hypertelorism, depressed nasal bridge, epicanthus, microstomy, high-arched palate, hypoplastic low-set ears, short neck, low hair line, and arachnodactyly. The baby had a pronounced progeroid appearance. The subcutaneous fat layer was not pronounced. An external examination of the genitals revealed hypoplasia of the labia majora, and the clitoris was hypertrophied. The liver protruded 3 cm below the edge of the right costal arch and 1 cm below the edge of the left costal arch. Motor activity was reduced.\nUpon screening at 9 months, the patient’s condition was severe, but her consciousness was clear, and her posture as active. The baby was responsive to communication. She had a body weight of 3.3 kg (Z-score −6.54), a height of 54 cm (Z-score −6.61), and a body mass index of 11.32 (Z-score −4.67). Her head circumference was 43.5 cm (Z-score −0.76), and her chest circumference was 30 cm. The patient’s physical development was extremely low, disharmonic. Pseudohydrocephalus, high forehead, triangular face, exophthalmos, narrow nasal dorsum, smooth philtrum, microgenia, microtia, and arachnodactyly were observed in the child during the examination. The skin was clean and dry. The girl had cyanosis of the face and upper half of the trunk when crying. The subcutaneous fat was underdeveloped. The patient’s chest was barrel-shaped. Hepatomegaly was observed. The child could not support her head but tried to turn her body from prone to supine. She had a pronounced interest in toys. Her speech consisted of babbling, with chains of syllables. X-ray showed delay in bone age – less than three months vs the patient’s actual age of 9 months. The bone structure was sparse. Valgus deformity of the knee joints was observed. Data on the condition of the patella were not provided because these bones are transparent on X-ray scans in young children, and ultrasonography was not performed. EEG recordings contained no epileptiform or focal pathological activity. Echocardiography showed no signs of heart defects. Patent foramen ovale and diagonal trabecula in the left ventricular cavity were observed.\nAnother examination was performed at 1 year and 3 months was performed. The girl had a height of 58 cm (Z-score −7.06), a weight of 4 kg (Z-score −6.44) and a head circumference of 45 cm (Z-score −0.5). Hydrocephalic head, high forehead, triangular face, exophthalmos, narrow nasal dorsum, microgenia, microtia, severe hypotrophy, and areas of alopecia on the head were observed. Subcutaneous fat was not developed. The baby did not sit independently and could not steadily support herself on her feet, but she was able to stand with support. She played with toys, held objects in her hands, collected pyramids, and transferred small objects.\nThe last time the patient was examined when she was 1 year 11 months old. Short stature (63 cm, Z-score −7.04) and growth retardation (5 kg, Z-score −6.16) were noted. Clinical examination revealed dysmorphic facial features, microtia. Absent patella was noted by palpation. .\nInitially, chromosomal abnormality was suspected in the child. Cytogenetic testing was performed. Karyotype 46, XX was detected. Hutchinson-Gilford progeria was assumed. A corresponding study of the LMNA gene was performed. No pathogenic changes were observed. Clinical exome sequencing was ordered, identifying two variants in the CDC6 gene. Parental examination revealed that they were heterozygous carriers of relevant changes in the nucleotide sequence.\nNeither variant had been registered in either the GnomAD database (v.2.1.1), the clinical databases (Clinvar, HGMD Professional (v.2021.1)), or the database of variants obtained by exome sequencing (WES, CES) in the Research Center for Medical Genetics – RuExac (1337 samples). The exon 3 nucleotide sequence variant of the CDC6 gene (chr17:38447363C>T) results in a premature translation termination site (p.(Gln78Ter), NM_001254.3). According to the pathogenicity criteria, ACMG is classified as pathogenic (PVS1, PS3, PM2). The criterium PS3 was used due to the previously functional study that demonstrated pathogenicity of LoF variants in the CDC6 gene. A variant in exon 3 of the CDC6 gene (chr17:38447361A>G), resulting in a missense replacement of (p.(Lys77Arg), NM_001254.3), is classified as a variant with uncertain clinical significance (ACMG: PM2, PM3).", "summary": "The patient, a female, had extremely low physical development, neonatal progeroid appearance, lipodystrophy, thin skin, partial alopecia, cyanosis of the face, triangular face, microgenia, arachnodactyly, delayed bone age, hepatomegaly, hypoplasia of the labia majora, and hypertrophy of the clitoris in addition to known clinical signs. Differential diagnosis was performed with chromosomal abnormalities and Hutchinson-Gilford progeria. According to the results of sequencing of the clinical exome, the patient had two previously undescribed variants in the CDC6 gene, c.230A>G (p.(Lys77Arg)) and c.232C>T (p.(Gln78Ter)), NM_001254.3, in a compound heterozygous state.", "subclaim_evaluations": [ { "subclaim": "The patient is female.", "support_label": "supported" }, { "subclaim": "The patient had extremely low physical development.", "support_label": "supported" }, { "subclaim": "The patient had a neonatal progeroid appearance.", "support_label": "supported" }, { "subclaim": "The patient had lipodystrophy.", "support_label": "supported" }, { "subclaim": "The patient had thin skin.", "support_label": "supported" }, { "subclaim": "The patient had partial alopecia.", "support_label": "supported" }, { "subclaim": "The patient had cyanosis of the face.", "support_label": "supported" }, { "subclaim": "The patient had a triangular face.", "support_label": "supported" }, { "subclaim": "The patient had microgenia.", "support_label": "supported" }, { "subclaim": "The patient had arachnodactyly.", "support_label": "supported" }, { "subclaim": "The patient had delayed bone age.", "support_label": "supported" }, { "subclaim": "The patient had hepatomegaly.", "support_label": "supported" }, { "subclaim": "The patient had hypoplasia of the labia majora.", "support_label": "supported" }, { "subclaim": "The patient had hypertrophy of the clitoris.", "support_label": "supported" }, { "subclaim": "Differential diagnosis included chromosomal abnormalities.", "support_label": "supported" }, { "subclaim": "Differential diagnosis included Hutchinson-Gilford progeria.", "support_label": "supported" }, { "subclaim": "The patient had two previously undescribed variants in the CDC6 gene.", "support_label": "supported" }, { "subclaim": "The variants were c.230A>G (p.(Lys77Arg)) and c.232C>T (p.(Gln78Ter)).", "support_label": "supported" }, { "subclaim": "The variants were in the CDC6 gene, NM_001254.3.", "support_label": "supported" }, { "subclaim": "The variants were in a compound heterozygous state.", "support_label": "supported" } ] }, { "id": "multiclinsum_test_110_en.txt", "fulltext": "A 14-year-old Han Chinese woman with a history of neurogenic bladder for more than 10 years was admitted to our Department because of coma for 12 h. The patient complained for diplopia without fever or diarrhea 4 days before her coma with no incentive. She had no limb weakness and was treated with Vitamin B1and mecobalamine. Her previous medical history included neurogenic bladder caused by spina bifida occulta for 12 years and hydronephrosis diagnosed 1 year before. Sometimes she had urine retention, but she received no treatment for the neurogenic bladder except for urethral catheterization occasionally. She had no seizures and no fever. On admission, physical examination revealed that she was unconscious. The pupils did not react to light and presented different sizes in each eye (left pupil diameter, 2.5 mm; right pupil diameter, 4 mm). On stimulation, she could move her 4 limbs spontaneously. There were exaggerated deep tendon reflexes over both legs and the right Barbinski sign was positive. However, her vital signs were stable: Blood Pressure (BP) was 120/81 mmHg; pulse rate, 76 beats/min; body temperature, 36.5 °C; breath, 12 times/min. Non-contrast brain computed tomography (CT) after the onset of her coma revealed diffuse brain stem hypodensity. Brain MRI acquired 4 h after the coma onset in the county hospital showed high signal at the dorsal part of the pontine base and the mid brain on fluid-attenuated inversion-recovery (FLAIR) imaging and T2-weighted imaging. However, diffusion-weighted images presented normal signal . The non- contrast abdominal CT preformed on the next day of admission showed chronic obstructive uropathy with a distended bladder, severe hydronephrosis and dual renal atrophy.\nBlood analysis immediately after admission revealed renal failure [Urea nitrogen: 23.87 mmol/L, Creatinine: 566.8 μmol/L], and anemia [RBC: 2.5 × 1012/L, HGB: 79 g/L]. Arterial blood gas analysis revealed metabolic acidosis [pH 7.09 (7.35–7.45)]. Liver function was normal.\nThe patient was diagnosed with UE due to chronic renal failure and metabolic acidosis. She was immediately treated with 200 ml of bicarbonate at 5% conducted by quick intravenous injection, followed by 100 ml intravenous injection of bicarbonate at 5% once a day and 1.0 g of bicarbonate administered orally three times per day for 3 days. Simultaneously, she underwent urethral catheterization to relieve the urine retention. She was revived without diplopia 3 days after admission and the reviewed blood analysis after urethral catheterization showed that her renal function was returning to a normal level (Urea nitrogen: 13.10 mmol/L, Creatinine: 294 μmol/L); hence, dialysis was not necessary. She was treated with hypodermically administered erythropoietin 3000u twice a day, and ferrous sulfate 0.3 g orally thrice a day for the anemia. She was discharged 14 days after the admission without diplopia and any mental disturbance. She was still with the ureteral catheter because of the hydronephrosis. Two weeks after the discharge, the catheter was removed when abdomen ultrasonic showed decreased hydronephrosis. Follow-up MRI performed 2 months after the discharge revealed complete resolution of the brainstem UE . Reviewed blood analysis after 2 months of discharge showed that her renal failure still persisted (Urea nitrogen: 13.10 mmol/L, Creatinine: 190.3 μmol/L). However, she had no neurological disturbance or urinary retention. She underwent the comprehensive bladder-retraining program to avoid urinary retention and her renal function was regularly assessed once a month.", "summary": "A 14-year-old Han Chinese woman with a history of chronic renal failure caused by neurogenic bladder. On admission, she was unconscious and her pupils presented different sizes, while her vital signs were normal. MRI showed high signal in the dorsal pontine base and in the mid brain on fluid-attenuated inversion-recovery (FLAIR) imaging and on T2-weighted imaging while the signal was normal on diffusion-weighted images (DWI). Blood analysis revealed renal failure and acidosis. After urinary retention treatment and acidosis correction, the patient soon recovered. Follow-up MRI 2 months after the discharge revealed complete resolution of UE in the brainstem.", "subclaim_evaluations": [ { "subclaim": "The patient is a 14-year-old Han Chinese woman.", "support_label": "supported" }, { "subclaim": "She has a history of chronic renal failure.", "support_label": "supported" }, { "subclaim": "Her chronic renal failure is caused by neurogenic bladder.", "support_label": "supported" }, { "subclaim": "On admission, she was unconscious.", "support_label": "supported" }, { "subclaim": "Her pupils presented different sizes.", "support_label": "supported" }, { "subclaim": "Her vital signs were normal.", "support_label": "supported" }, { "subclaim": "MRI showed high signal in the dorsal pontine base on FLAIR imaging.", "support_label": "supported" }, { "subclaim": "MRI showed high signal in the mid brain on FLAIR imaging.", "support_label": "supported" }, { "subclaim": "MRI showed high signal in the dorsal pontine base on T2-weighted imaging.", "support_label": "supported" }, { "subclaim": "MRI showed high signal in the mid brain on T2-weighted imaging.", "support_label": "supported" }, { "subclaim": "The signal was normal on diffusion-weighted images.", "support_label": "supported" }, { "subclaim": "Blood analysis revealed renal failure.", "support_label": "supported" }, { "subclaim": "Blood analysis revealed acidosis.", "support_label": "supported" }, { "subclaim": "After urinary retention treatment, the patient soon recovered.", "support_label": "supported" }, { "subclaim": "After acidosis correction, the patient soon recovered.", "support_label": "supported" }, { "subclaim": "Follow-up MRI 2 months after discharge revealed complete resolution of UE in the brainstem.", "support_label": "supported" } ] }, { "id": "multiclinsum_test_1227_en.txt", "fulltext": "A 6 years old boy with dyspnea, orthopnea, generalized pitting edema and fever, was admitted to the pediatric intensive care unit, Shanghai Children’s Hospital. Three years before this episode, he presented to our hospital with acute onset of edema, hypoalbuminemia, heavy proteinuria and hyperlipidemia. The diagnosis of IgA nephropathy (Grade II) was made by percutaneous renal biopsy and in accordance with Lee’s classification . Initially he responded well to steroid therapy, but became steroid resistant after 2 years treatment. Immunosuppressive agents administered during this time period, included cyclophosphamide, mycophenolate mofetil and tacrolimus. He had no history of trauma, tuberculosis or radiation therapy.\nPhysical examination revealed tachypnea, orthopnea, anasarca and ascites. The heart sounds were muffled and hepatomegaly was also noted. Blood pressure ranged from 90/60 mmHg (systolic/diastolic blood pressure) to 130/70 mmHg. Blood cell count showed that white blood cells (WBC) was 14.49 × 109/L, neutrophils 79%, hemoglobin 11.5 g/dl, C-reactive protein 130 mg/L. Biochemistry analysis revealed total protein of 36 g/L, albumin 10 g/L, alanine aminotransferase (ALT) 10 U/L, aspartate aminotransferase (AST) 29 U/L, triglycerides 2.05 mmol/L, cholesterol 10.13 mmol/L. Serum electrolytes (Na+, K+, Ca2+ and Cl−) were normal. Heavy proteinuria and hematuria were found on urinalysis (urinary protein: creatinine ratio 30.38). Serum creatinine was normal and estimated glomerular filtration rate (eGFR, calculated with Schwartz formula) was 147 ml/min/1.73m2. Blood and urine cultures were sterile. T-spot for tuberculosis was negative. There was no ultrasound evidence of thrombosis in the superior vena cava or subclavian vein. Ultrasound also demonstrated that both kidneys were enlarged with a loss of cortico-medullary differentiation. Thoracic computed tomography (CT) found no evidence of congenital malformation or malignancies. Echocardiography revealed pericardial fluid of 4.6 cm at maximal thickness, suggesting a large volume hydropericardial effusion. The massive pericardial and pleural effusions were additionally confirmed by thoracic CT . Notably, milky fluid was obtained from the pericardial space by pericardiocentesis . Chyle test was positive. Cell counts and biochemistry in the pericardial effusion revealed WBC 405 × 106/L, lymphocytes count 92%, red blood cells 63 × 106/L, AST 8 U/L, lactate dehydrogenase (LDH) 58 U/L, Glucose 7.22 mmol/L, total protein 7 g/L, albumin 4 g/L, adenylate deaminase (ADH) 2.6 U/L, triglycerides 2.55 mmol/L, cholesterol 0.79 mmol/L. These findings confirmed the diagnosis of chylopericardial effusion.\nContinuous renal replacement (CRRT) therapy was performed to alleviate the fluid overload. Meanwhile, pericardial drainage was performed and the diet was modified to low fat but rich in middle chain triglycerides and high protein. No side effects were encountered with this diet modification. The symptoms of cardiac tamponade subsided promptly, while the edema receded gradually over the subsequent 2 weeks. The indwelling pericardial catheter was removed when no fluid was drained after 3 weeks treatment and as shown in Fig. , the chylopericardial effusion was removed successfully. Pericardial effusion has not recurred at 1 year of follow up, on follow up echocardiography.", "summary": "A 6 years old boy with IgA nephropathy presented with dyspnea, orthopnea, pretibial pitting edema, ascites and fever. Muffled heart sounds and hepatomegaly were also noted. Echocardiography and thoracic CT revealed that there was a large volume of hydropericardium. Moreover, the pericardial milky fluid by pericardiocentesis was analyzed and chylopericardium effusion was eventually confirmed. Pericardial drainage was continued and his diet was modified to low fat, rich MCT and high protein. Complete remission was achieved after 3 weeks of this combined treatment.", "subclaim_evaluations": [ { "subclaim": "The patient is a 6-year-old boy.", "support_label": "supported" }, { "subclaim": "The patient has IgA nephropathy.", "support_label": "supported" }, { "subclaim": "The patient presented with dyspnea.", "support_label": "supported" }, { "subclaim": "The patient presented with orthopnea.", "support_label": "supported" }, { "subclaim": "The patient had pretibial pitting edema.", "support_label": "not_supported" }, { "subclaim": "The patient had ascites.", "support_label": "supported" }, { "subclaim": "The patient had fever.", "support_label": "supported" }, { "subclaim": "Muffled heart sounds were noted.", "support_label": "supported" }, { "subclaim": "Hepatomegaly was noted.", "support_label": "supported" }, { "subclaim": "Echocardiography revealed hydropericardium.", "support_label": "supported" }, { "subclaim": "Thoracic CT revealed hydropericardium.", "support_label": "supported" }, { "subclaim": "Pericardiocentesis was performed.", "support_label": "supported" }, { "subclaim": "The pericardial fluid was milky.", "support_label": "supported" }, { "subclaim": "Chylopericardium effusion was confirmed.", "support_label": "supported" }, { "subclaim": "Pericardial drainage was continued.", "support_label": "supported" }, { "subclaim": "The patient's diet was modified to low fat.", "support_label": "supported" }, { "subclaim": "The patient's diet was modified to include rich MCT.", "support_label": "supported" }, { "subclaim": "The patient's diet was modified to include high protein.", "support_label": "supported" }, { "subclaim": "Complete remission was achieved after 3 weeks of treatment.", "support_label": "supported" } ] }, { "id": "multiclinsum_test_1797_en.txt", "fulltext": "A 48-year-old woman underwent a skin-sparing mastectomy for ductal carcinoma of the right breast.\nWe immediately reconstructed the breast using a deep inferior epigastric artery perforator (DIEP) free flap from the lower abdomen. The pedicle of the recipient was the thoracodorsal artery and its venae comitantes, which are commonly used in breast reconstruction. The surgery was successfully performed, and the patient was on the usual course without any postoperative complications . However, on postoperative day 7, she suffered a deep second- to third-degree contact burn over 30 percent of the reconstructed right breast due to incorrect application of a heating pad at the flap site .\nDuctal carcinoma of the right breast.\nThe burn wound was initially treated with a conventional dressing; however, the necrotic changes progressed with eschar formation . Therefore, we performed en bloc resection of the necrotic tissue at the 21st d postburn. During eschar resection, we confirmed flap survival by observing surviving glistening yellow adipose tissue in the subdermal layer .\nAs the Doppler sound of the flap pedicle was also traceable, we applied a V.A.C. dressing (KCI International, San Antonio, TX, USA) to promote healing of the burn wounds. We sealed it entirely over the exposed area of the patient’s right breast under a pressure of -125 mmHg in continuous mode. However, after four days of V.A.C. application, the burn wound worsened, and the exposed adipose tissue changed to dry and brown-colored necrotic tissue . Upon further debridement, we observed an obstructed vascular pedicle with multiple thrombi in the transferred DIEP flap tissue . We also observed the presence of unviable adipose tissue. First, we performed daily dressing to demarcate the necrotic tissue.", "summary": "A 48-year-old woman who underwent immediate breast reconstruction with a deep inferior epigastric artery perforator free flap. While applying a heating pad directly to the flap site, she sustained a deep second to third-degree contact burn over 30% of the transferred flap on postoperative 7 d. As the necrotic changes had progressed, we applied an NPWT dressing over the burned area after en-bloc debridement of the transferred tissues on postoperative 21 d. After 4 d of NPWT application, the exposed fatty tissues of the flap changed to dry and brown-colored necrotic tissues. Upon further debridement, we noted that the wound gradually reached total necrosis with a collapsed vascular pedicle of deep inferior epigastric artery.", "subclaim_evaluations": [ { "subclaim": "The patient is a 48-year-old woman.", "support_label": "supported" }, { "subclaim": "She underwent immediate breast reconstruction.", "support_label": "supported" }, { "subclaim": "The reconstruction was performed with a deep inferior epigastric artery perforator free flap.", "support_label": "supported" }, { "subclaim": "She sustained a deep second to third-degree contact burn.", "support_label": "supported" }, { "subclaim": "The burn occurred over 30% of the transferred flap.", "support_label": "supported" }, { "subclaim": "The burn occurred on postoperative day 7.", "support_label": "supported" }, { "subclaim": "The burn was caused by applying a heating pad directly to the flap site.", "support_label": "supported" }, { "subclaim": "Necrotic changes had progressed.", "support_label": "supported" }, { "subclaim": "An NPWT dressing was applied after en-bloc debridement.", "support_label": "supported" }, { "subclaim": "The debridement was performed on postoperative day 21.", "support_label": "supported" }, { "subclaim": "After 4 days of NPWT application, the exposed fatty tissues changed to dry and brown-colored necrotic tissues.", "support_label": "supported" }, { "subclaim": "Upon further debridement, the wound reached total necrosis.", "support_label": "not_supported" }, { "subclaim": "The vascular pedicle of the deep inferior epigastric artery was noted to be collapsed.", "support_label": "not_supported" } ] }, { "id": "multiclinsum_test_3031_en.txt", "fulltext": "A 18-year-old previously healthy female (165 cm, 65 kg, body mass index (BMI) 23.9), without pre-existing comorbidities or a family history for cardiac pathologies, was admitted to the cardiac care unit (CCU) at nine o’clock with cold-like symptoms and progressive dyspnea after five days of cold-like symptoms (fever, cough and expectoration). She had shortness of breath, palpitation (Heart rate: 156 beats per minute), and hypotension [Blood pressure (BP): 98/58 mmHg without vasoactive drugs usage]. Upon examination at an external hospital, a pulmonary computerized tomography (CT) revealed indications of cardiogenic pulmonary edema and moderate pulmonary inflammation. The patient presented upon admission in an alert and coherent state, but with a diminished overall condition, exhibiting sinus tachycardia at a rate of 150–160 beats per minute and experiencing oxygenation impairment. Due to hypoxia, the patient necessitated supplemental oxygen administration through both nasal cannula (at a flow rate of 3 L per minute) and mask inhalation (at a flow rate of 6 L per minute) to maintain a transcutaneous pulse oxygen saturation (SPO2) level of approximately 93%. The arterial blood gas analysis revealed a pH value of 7.44, a partial pressure of oxygen of 93 mmHg, and a partial pressure of carbon dioxide of 32 mmHg following the administration of oxygen.\n\nThe patient reported no history of smoking or alcohol consumption. Additionally, there was no evidence of illicit drug use, immune-checkpoint inhibitor usage, or anti-tuberculosis medication intake. The patient received two doses of the Coronavirus Disease 2019 (COVID-19) vaccine on July 26th and August 17th, 2021, respectively. The patient contracted COVID-19 infection three months prior as a result of the implementation of a “herd immunity” policy.\n\nLaboratory results on admission showed an increased aspartic transaminase (AST) level of 56 IU/L, creatine kinase (CK) level of 373 IU/L, creatine kinase-MB (CK-MB) level of 36.5 IU/L, troponin I (TnI) level of 4.1 ng/mL (reference range: < 0.02 pg/mL), N-terminal pro brain natriuretic peptide (NT-proBNP) levels of 14,100 pg/mL, and serum creatinine levels of 119 umol/L. The lactate value was 1.7 mmol/L. The D-dimer was in the normal range (1.590mg/L). In addition, the inflammatory markers of white blood cell count, absolute neutrophil count, serum C-reactive protein (CRP), serum procalcitonin, amyloid A and interleukin 6 were 8.27×10^9/L, 6.26×10^9/L, 124.05 mg/L, 0.768ng/mL, 1114.5mg/L and 6235.0pg/mL, respectively. Thyroid function test suggested that hypersensitive thyrotropin (TSH) was decreasing (0.39 mIU/L), but triiodothyronine (T3) and tetraiodothyronine (T4) were normal.\n\nTwelve lead electrocardiogram (ECG) admitted to hospitalization (April 13th, 2023) demonstrated sinus tachycardia. ECG showed QS complex only in V1-V3 leads and 1–2 mm ST-segment depression in II, III, aVF, V4-V6 leads. Chest radiograph showed bilateral pulmonary scattered inflammatory changes and possible pulmonary oedema after IABP implantation. After a period of treatment, the ECG findings on April 18th revealed flat or inverted T waves in leads V1-V6. On April 19th, chest radiograph showed no signs of pulmonary congestion or inflammation.\n\nThe transthoracic echocardiography (TTE) revealed a severely impaired left ventricular ejection fraction (LVEF ~35.7%), a moderately reduced right ventricular function [tricuspid annular plane systolic excursion (TAPSE) =12 mm)], moderate to severe regurgitation of the mitral valve and tricuspid valve (the estimated pulmonary artery systolic blood pressure was 49 mmHg). The inferior vena cava was widened and its’ respiratory collapse rate was less than 50%. The patient was admitted with a diagnosis of fulminant myocarditis: acute heart failure, cardiac function Grade III (New York Heart Association classification system); pulmonary infection; upper respiratory tract infection.\n\nDue to the patient’s hemodynamic instability caused by acute heart failure, a continuous intravenous treatment regimen was administered. This included furosemide (4.1 ug/kg/min), dopamine (2.5 ug/kg/min), and metaraminol bitartrate injection (0.2 ug/kg/min) using microinjection pumps. Additionally, methylprednisolone sodium succinate (320 mg daily) was intravenously administered for five consecutive days to inhibit myocardial inflammation, while being protected by intravenous human immunoglobulin (PH4, 20 mg daily). Pulmonary infection was managed through transvenous administration of cefuroxime sodium every eight hours.\n\nDrug and Instrumental Treatment\nThree hours after admission, the patient exhibited a gradual progression into cardiogenic shock, specifically reaching the classic stage as defined by the cardiogenic shock staging of the American Society for Angiocardiography and Intervention. This was characterized by hypotension (blood pressure: 97/50 mmHg with the use of vasoactive drugs) and severely impaired oxygen saturation (SPO2 80%) at twelve o’clock. The patient’s heart rate was measured at 148 beats per minute, and the lactate value was recorded as 2.9 mmol/L at that time. Despite the administration of dopamine and metaraminol bitartrate to stabilize the patient’s vital signs, the cardiogenic shock remained uncorrected.\n\nThus, an IABP was initially used for cardiogenic shock management in cardiac catheterization room in hospital day one. An IABP device (Impella cardiac power, IAB-06840-U; Teleflex®, Arrow International LLC, USA) was placed to decrease afterload and improved diastolic BP in order to increase pulsatility and improve coronary perfusion. Because of reduced vigilance and ongoing hemodynamic instability, the patient was intubated and ventilated. Subsequently, on the first day of hospitalization in the evening, femoro-femoral veno-arterial extracorporeal membrane oxygenation (VA-ECMO) was administered using the Cardiohelp device (Getinge AB, Göteborg, Sweden). Following initiation, there was a partial reduction in aortic valve opening, leading to the discontinuation of metaraminol bitartrate. Additionally, a daily administration of human blood albumin (10 g) was implemented to enhance colloid osmotic pressure. Furthermore, fresh frozen plasma was administered to improve coagulation function and minimize the risk of bleeding associated with the instrumentation.\n\nOn the first day following the initiation of IABP (Counterpulsation pressure: 110 mmHg) and VA-ECMO (Rotation speed: 3495 RPM/min; Flow: 2.62 L/min), TTE still indicated a decrease in myocardial contractility, with an LVEF of 36.6%. High dose of dopamine combined with furosemide were continued as treatment, while the invasive radial arterial BP was measured at 95/56 mmHg. By the third day after instrument implantation, there was an improvement in myocardial contractility and hemodynamic stabilization was achieved, resulting in a gradual reduction in vasopressor levels to 1.5 ug/kg/min. Thus, extracorporeal membrane oxygenation (ECMO) was discontinued on the fourth day after implantation, resulting in arterial blood pressure (BP) of 112/72 mmHg without the use of dopamine. Due to the patient’s hemodynamic stability, the intra-aortic balloon pump (IABP) was removed on the fifth day after implantation, resulting in arterial BP of 114/74 mmHg. The patient experienced a rapid recovery, as mechanical ventilation was discontinued the following day and arterial BP remained at 112/72 mmHg.\n\nEight days after she was admitted, TTE revealed that the patient had a normalized cardiac function with no sign of persisting heart failure (left ventricular end diastolic diameter (LVEDD), 42.5 mm; interventricular septum thickness (IVS), 10.5 mm; LVEF, 50.8%). We stopped using diuretics because of almost normal cardiac function.\n\nEtiology\nCoronary angiography revealed no artery stenosis in hospital day one. Fulminant myocarditis may be caused by a variety of factors, including viral, bacterial, toxic, and autoreactive. In this patient, legionella pneumophila A IgM antibody, mycoplasma and chlamydia IgM antibody, adenovirus IgM antibody, respiratory syncytial virus IgM antibody, influenza virus A and B IgM antibody, and parainfluenza virus antibody were negative. The laboratory test of toxoplasmosis, cytomegalovirus, rubivirus, herpes simplex virus type 1 and 2, parvovirus B19 IgM antibody showed negative but IgG antibody revealed positive. In addition, SARS-CoV-2 RNA was negative through the throat swab test.\n\nThe antinuclear antibody (ANA) was weakly positive (Spotty type 1:100), anti-mitochondrial antibody M2 was positive, anti-Ro-52 antibody and anti-SS-A antibodies were strongly positive. Both myeloperoxidase-ANCA (MPO-ANCA) and proteinase 3-ANCA (PR3-ANCA) were negative. Anti-double-stranded DNA and other autoimmunity anti-body were negative. We considered the patient might suffer from with Sjogren’s syndrome but the labial gland biopsy data were lacking.\n\nFever and Depressive State\nOn hospital day 8, the patient developed fever, with body temperature fluctuating between 38 and 39 degrees. In addition, the inflammatory markers of white blood cell count, absolute neutrophil count, serum CRP and procalcitonin were 23.91×10^9/L, 20.69×10^9/L, 11.04 mg/L and 0.62 ng/mL, respectively. Serological tests for tuberculosis (T-SPOT, TB test), Widal reaction and blood cultures were negative. On the eighth day of hospitalization, a lung CT scan exhibited dispersed streaks in the lower right lung, prompting a modification in the antibiotic regimen to piperacillin sulbactam (4.5g intravenous every eight hours). Nevertheless, by the tenth day of hospitalization, the patient’s temperature did not show any signs of reduction, raising doubts regarding the association between the fever and the progression of pneumonia. Subsequently, on the eleventh day of hospitalization, a comprehensive abdominal CT scan revealed colorectal dilatation, necessitating heightened awareness for the possibility of paralytic intestinal obstruction. Following the administration of warm saline retention enema, the patient’s body temperature rapidly declined the following day.\n\nMoreover, the patient exhibited notable levels of anxiety, depression, and suicidal inclinations on the ninth day of hospitalization. To address these concerns, psychological counseling therapy and the administration of sertraline hydrochloride tablets were implemented. Over time, the patient experienced a gradual recovery, leading to their transfer to the intermediate care unit on the thirteenth day and eventual discharge on the fourteenth day. Follow-up for seven month after discharge showed the patient had no chest tightness and shortness of breath after activity and the cardiac function was maintained at grade I (New York Heart Association classification system).", "summary": "The current report described a severe instance of fulminant myocarditis in an 18-year-old young woman who presented with severe hypoxemia and hemodynamic instability. The patient was treated with a combination of optimal medical therapy, immunological modulation, extracorporeal membrane oxygenation (ECMO), and an intra-aortic balloon pump (IABP) to support him through his critical period of hemodynamic collapse.", "subclaim_evaluations": [ { "subclaim": "The report described a case of fulminant myocarditis.", "support_label": "supported" }, { "subclaim": "The patient was an 18-year-old woman.", "support_label": "supported" }, { "subclaim": "The patient had severe hypoxemia.", "support_label": "supported" }, { "subclaim": "The patient had hemodynamic instability.", "support_label": "supported" }, { "subclaim": "The patient was treated with optimal medical therapy.", "support_label": "not_supported" }, { "subclaim": "The patient received immunological modulation.", "support_label": "supported" }, { "subclaim": "The patient was supported with extracorporeal membrane oxygenation (ECMO).", "support_label": "supported" }, { "subclaim": "The patient was treated with an intra-aortic balloon pump (IABP).", "support_label": "supported" } ] }, { "id": "multiclinsum_test_1357_en.txt", "fulltext": "A female aged two years and 11 months was brought to the ED by ambulance for a generalized tonic-clonic first-time seizure. The patient had otherwise been in her usual state of health with no recent febrile illnesses. Her mother noted that the patient had an acute episode of unresponsiveness with a blank stare and called 9–1–1. Upon emergency medical services arrival, the child developed generalized tonic-clonic seizure activity. She received a weight-based dose of 1.7 milligrams (mg) of midazolam en route to the hospital, which resolved the movements. Upon arrival to the hospital, the child was no longer actively seizing and appeared to be sleepy, consistent with a postictal state. The estimated total seizure length was approximately two minutes. The patient had no notable past medical history. Family history was notable for Graves disease in the patient’s mother.\nVital signs on arrival were as follows: temperature 37.9° Celsius measured rectally; heart rate 188 beats per minute; respiratory rate 27 breaths per minute; and blood pressure 125/62 millimeters of mercury. Her height was 103 centimeters, 99th percentile, and her weight was 16 kilograms, 87th percentile. Her physical exam was notable for exophthalmos and small goiter but was otherwise unremarkable, including a non-focal neurological examination. Of note, her tachycardia and widened pulse pressure persisted after resolution of her seizure and postictal period.\nHer electrocardiogram was notable for left ventricular hypertrophy and sinus tachycardia but had no evidence of ischemia or abnormal intervals. Her laboratory evaluation was notable for a normal fingerstick blood glucose, elevated alkaline phosphatase with mild transaminitis, mild microcytic anemia, undetectably low thyroid-stimulating hormone (TSH) and unmeasurably high free thyroxine.\nThe pediatric endocrinologist was consulted who, based on the patient’s weight, recommended starting atenolol 12.5 mg, methimazole 7.5 mg, and 1 milliliter (mL) potassium iodide-iodine (Lugol’s saturated solution of potassium iodide {SSKI}) solution (to be given one hour after atenolol and methimazole). After treatment was initiated, the patient’s heart rate improved to the 160s, and she was admitted to the pediatric intensive care unit (PICU). While in the PICU, further levels were obtained and were notable for unmeasurably high free triiodothyronine (T3), unmeasurably high total T3, and elevated thyroid-stimulating immunoglobulins (328% baseline). While in the PICU, the patient was continued on atenolol, methimazole, Lugol’s solution, and hydrocortisone 50 mg every eight hours. She was in the PICU for approximately 24 hours and then transferred to the medical ward.\nThe patient remained in the hospital for one week and was discharged home with methimazole, propranolol, and SSKI. She was followed in endocrinology clinic multiple times over the next few months. The SSKI was eventually stopped, and propranolol was changed to atenolol. She had trouble with compliance with medications as the formulations available for atenolol are not child friendly. She was referred to another hospital system for a total thyroidectomy given inability to tolerate swallowing pills. She has not had recurrent seizure activity since initiating thyroid treatment.", "summary": "We describe the case of a 3-year-old girl who presented to the ED with an afebrile seizure but was found to be in thyroid storm. This case should serve as a reminder for emergency physicians to consider thyroid disease when evaluating patients presenting with seizures.", "subclaim_evaluations": [ { "subclaim": "The patient was a 3-year-old girl.", "support_label": "not_supported" }, { "subclaim": "The patient presented to the ED with an afebrile seizure.", "support_label": "not_supported" }, { "subclaim": "The patient was found to be in thyroid storm.", "support_label": "supported" }, { "subclaim": "Emergency physicians should consider thyroid disease when evaluating patients presenting with seizures.", "support_label": "supported" } ] }, { "id": "multiclinsum_test_1328_en.txt", "fulltext": "A 28-year-old man complained of an abdominal mass and continuously increasing pain over the previous 2 months. Physical examination revealed a midabdominal mass on abdominal palpation, atrophy and minimal induration in the right testis on scrotal palpation. The left testis was found to be normal. No abnormal finding was noted on digital rectal examination. Examination of the other systems, including the endocrine system, was normal.\nHis white blood cell count and urine microscopy were normal. Aspartate aminotransferase (AST): 56 mg/dl (normally 1 to 40), alanine aminotransferase (ALT): 42 mg/dl (normally 1 to 38), alkaline phosphatase (ALP): 768 mg/dl (normally 80 to 306), gamma glutamyl transferase (GGT): 160 mg/dl (normally 6 to 50) and lactate dehydrogenase (LDH): 6302 mg/dl (normally 266 to 501) were found in the blood biochemistry. His erythrocyte sedimentation rate was high (110 mm/hour). Values for alpha-fetoprotein (AFP) (5.9 ng/ml (normally 0 to 10.0)) and beta human chorionic gonadotrophin hormone (β-hCG) (0.773 mIU/ml (normally <4)) were within normal limits. Chest X-ray was normal. Scrotal ultrasonogram revealed minimal hypoechogeneity and non-homogeneity in the right testis. Abdominal computed tomography (CT) revealed a very large retroperitoneal mass (13×8 cm), extending across the midline . Thorax CT was normal.\nNeedle aspiration biopsy was performed for the retroperitoneal mass and malignant tumour infiltration was reported. After the immunohistochemical studies, cytokeratin (CK) (-), vimentin (-), leukocyte common antigen (LCA) (-), β-hCG (-) and placental alkaline phosphatase (PLAP) (+) immunoreactivity were noted, indicating a germ cell tumour.\nScrotal ultrasonogram revealed hypoechogeneity and non-homogeneity in the right testicle. Evidence of a tumour was not found. The left testicle and epididymis were normal. After pre-operative evaluation, right inguinal orchiectomy was performed to determine the primary site of the tumour. Histological examination of the biopsy specimen revealed a large area of hyalinization, tubular hyalinization, interstitial fibrosis and focal Leydig cell hyperplasia. There were no pathological findings in the epididymis and spermatic cord. The final pathological diagnosis was 'burned-out' testicular tumour .\nBecause of the large retroperitoneal lymph node metastasis, primary chemotherapeutic treatment was performed. Combination chemotherapy, consisting of bleomycin, etoposide and cisplatin, was given in three weekly cycles of four courses. After the four courses of chemotherapy treatment, the abdominal mass had regressed from 13×8 cm to 3×2 cm .\nAfter the chemotherapy, a control CT scan was obtained revealing regression in the para-aortic and para-caval lymph nodes (3×2 cm and multiple lymph nodes). After 6 months, tumour markers had increased (AFP: 3.59 ng/ml (normally 0 to 10.0) and β-hCG: 20.95 mIU/ml (normally <4)). Because only the β-hCG level had increased, the histology of the primary tumour seemed to indicate a seminoma. For this reason, retroperitoneal lymph node dissection was planned. Exploratory laparotomy revealed a retroperitoneal mass which extended both sides of the midline and involved the major vessels and extended to the eosophogastric junction, indicating an unresectable mass. A biopsy was performed from the unresectable mass and histological examination of the biopsy specimen showed only necrotic tissue and no tumour cells.\nSalvage chemotherapy consisting of paclitaxel, ifosfamide and cisplatin (TIP) was given in monthly cycles of four courses. After this chemotherapy, an abdominal CT scan revealed regression in the para-aortic and para-caval lymph nodes (milimetrical). AFP and β-hCG levels were normal (AFP: 1 ng/ml (normally 0 to 10.0) and β-HCG: 0.180 mIU/ml (normally <4)).\nThe patient has been disease and recurrence free for 5 years since the primary surgical and medical treatment.", "summary": "A 28-year-old man complained of an abdominal mass and continuously increasing pain over the previous 2 months. A midabdominal mass, atrophy and minimal induration in the right testis were revealed on physical examination. Ultrasound findings revealed focally increased echogenicity, which is typical of burned-out tumours. Inguinal orchiectomy was performed, and the histological examination of the biopsy specimen revealed a large area of hyalinization, tubular hyalinization, interstitial fibrosis and focal Leydig cell hyperplasia, with no abnormal pathological findings in the epididymis and spermatic cord. The final pathological diagnosis was concluded as \"burned-out\" testicular tumour. Surgical treatment was followed by appropriate chemotherapy and in the follow-up, the abdominal mass was observed to regress. The patient is currently free of disease 5 years after diagnosis.", "subclaim_evaluations": [ { "subclaim": "The patient is a 28-year-old man.", "support_label": "supported" }, { "subclaim": "The patient complained of an abdominal mass.", "support_label": "supported" }, { "subclaim": "The patient had continuously increasing pain over the previous 2 months.", "support_label": "supported" }, { "subclaim": "A midabdominal mass was revealed on physical examination.", "support_label": "supported" }, { "subclaim": "Atrophy and minimal induration in the right testis were revealed on physical examination.", "support_label": "supported" }, { "subclaim": "Ultrasound findings revealed focally increased echogenicity.", "support_label": "not_supported" }, { "subclaim": "Focally increased echogenicity is typical of burned-out tumours.", "support_label": "not_supported" }, { "subclaim": "Inguinal orchiectomy was performed.", "support_label": "supported" }, { "subclaim": "The histological examination of the biopsy specimen revealed a large area of hyalinization.", "support_label": "supported" }, { "subclaim": "The histological examination revealed tubular hyalinization.", "support_label": "supported" }, { "subclaim": "The histological examination revealed interstitial fibrosis.", "support_label": "supported" }, { "subclaim": "The histological examination revealed focal Leydig cell hyperplasia.", "support_label": "supported" }, { "subclaim": "No abnormal pathological findings were found in the epididymis.", "support_label": "supported" }, { "subclaim": "No abnormal pathological findings were found in the spermatic cord.", "support_label": "supported" }, { "subclaim": "The final pathological diagnosis was concluded as 'burned-out' testicular tumour.", "support_label": "supported" }, { "subclaim": "Surgical treatment was followed by appropriate chemotherapy.", "support_label": "supported" }, { "subclaim": "The abdominal mass was observed to regress in follow-up.", "support_label": "supported" }, { "subclaim": "The patient is currently free of disease.", "support_label": "supported" }, { "subclaim": "The patient is 5 years post-diagnosis.", "support_label": "supported" } ] }, { "id": "multiclinsum_test_1257_en.txt", "fulltext": "This is a retrospective case study of a 56-year-old white man diagnosed as having an AOP infarct admitted to Umeå University Hospital, Sweden. The relevant radiology images were obtained from the hospital’s database (PACS) and evaluated by a neuroradiologist as bilateral paramedian thalamic infarcts as a result of an AOP occlusion. The medical records (SYStem Cross) at Umeå University Hospital were accessed and reviewed for his medical history, neurological work-up, and laboratory work-up (ROS). The diagnosis was based on symptoms of AOP infarction as described in the literature, radiological signs of AOP infarction, as well as exclusion of differential diagnoses.\nHe was taken to our emergency department (ED) after he was found unconscious in his home with open doors and windows. He developed ventricular fibrillation on arrival at our ED. Cardiopulmonary resuscitation (CPR) was immediately initiated and sinus rhythm (SR) was achieved on second defibrillation. He was then put on cardiopulmonary bypass for rewarming. A third ventricular fibrillation then occurred and SR was achieved on first defibrillation within seconds of onset. The total estimated duration of ventricular fibrillation was less than 2 minutes.\nHis medical history included overconsumption of alcohol. He smoked 20 cigarettes per day. On admission to our hospital there was no information available concerning his medication. On arrival at our ED his body temperature was 24.5 °C, blood pressure 145/70, heart rate 35 beats/minute, and respiratory rate 8 to 10 breaths/minute. Auscultation of his heart and lungs was unremarkable. He was unconscious with a Reaction Level Scale 85 (RLS-85) score of 4. RLS-85 gives a score between 1 and 8. An RLS-85 score of 4 indicates an unconscious patient who localizes but does not ward off when pain stimulated. He exhibited a slight anisocoria with his right pupil slightly bigger than his left.\nThe laboratory work-up at admission included moderate electrolyte disturbances and elevated liver enzymes. Drug and alcohol screens were negative.\nAn emergency CT of his head was performed and initially misinterpreted as normal with no signs of hemorrhage or acute infarction . In our intensive care unit (ICU), he was initially sedated and intubated with ventilator treatment. An attempt to extubate and wake him was made on day 3, but he still required ventilator support. He was re-intubated and sedated, and later given a tracheotomy. A complicated disease course followed with pneumothorax after CPR, pneumonia treated with antibiotics, bilateral pleural effusion requiring drainage, intestinal paralysis, acute pancreatitis, and ascites requiring paracentesis. The sedation was discontinued 2 weeks after admission to our ICU. He still required ventilation support. At this stage he could open his eyes when spoken to but otherwise he gave no contact. On neurological examination he withdrew his arms, moved his left foot, and grimaced upon pain stimulation. He had slight anisocoria, this time with his left pupil slightly bigger than his right. His pupillary reflexes were, however, symmetrical on direct and indirect stimulation. A follow-up CT performed on day 24 revealed bilateral ischemia in the medial areas of the thalami, as well as a smaller ischemic area in the left part of pons . At this point a senior neuroradiologist re-evaluated the first CT performed on admission and concluded that bilateral thalamic ischemia was discernable also on this CT . Electroencephalography (EEG) was pathological and showed an irregular theta/delta activity. However, there was no epileptiform activity.\nFour weeks after admission it was possible to extubate him. His neurological function remained unchanged. He was transferred to our medical acute ward. On day 35 of hospitalization he died and the postmortem examination revealed pulmonary infarctions and pneumonia. A timeline of events is given in Fig. .", "summary": "This is a retrospective case study of a 56-year-old white man admitted to Umeå University Hospital and diagnosed with an artery of Percheron infarction. Medical records and the neuroradiological database were reviewed, and the diagnosis was made based on typical symptoms and radiological findings of artery of Percheron infarction. We report the case of a 56-year-old man with a history of overconsumption of alcohol who was found in his home unconscious and hypothermic. He had a Reaction Level Scale-85 score of 4. He developed ventricular fibrillation on arrival at our emergency department, and cardiopulmonary resuscitation successfully restored sinus rhythm within an estimated 2 minutes of onset. He was then put on cardiopulmonary bypass for rewarming. The initial head computed tomography performed on admission was wrongly assessed as unremarkable. Bilateral ischemia in the paramedian thalamic nuclei and pons were first documented on a follow-up computed tomography on day 24 after hospitalization. He died on day 35 after hospitalization.", "subclaim_evaluations": [ { "subclaim": "The patient was a 56-year-old white man.", "support_label": "supported" }, { "subclaim": "He was admitted to Umeå University Hospital.", "support_label": "supported" }, { "subclaim": "He was diagnosed with an artery of Percheron infarction.", "support_label": "supported" }, { "subclaim": "The diagnosis was made based on typical symptoms and radiological findings.", "support_label": "supported" }, { "subclaim": "The patient had a history of overconsumption of alcohol.", "support_label": "supported" }, { "subclaim": "He was found unconscious and hypothermic in his home.", "support_label": "supported" }, { "subclaim": "He had a Reaction Level Scale-85 score of 4.", "support_label": "supported" }, { "subclaim": "He developed ventricular fibrillation on arrival at the emergency department.", "support_label": "supported" }, { "subclaim": "Cardiopulmonary resuscitation restored sinus rhythm within an estimated 2 minutes.", "support_label": "supported" }, { "subclaim": "He was put on cardiopulmonary bypass for rewarming.", "support_label": "supported" }, { "subclaim": "The initial head computed tomography performed on admission was wrongly assessed as unremarkable.", "support_label": "supported" }, { "subclaim": "Bilateral ischemia in the paramedian thalamic nuclei and pons was first documented on a follow-up computed tomography on day 24 after hospitalization.", "support_label": "supported" }, { "subclaim": "He died on day 35 after hospitalization.", "support_label": "supported" } ] }, { "id": "multiclinsum_test_547_en.txt", "fulltext": "A 48-year-old male reported pain in the lateral part of his left lower leg and ankle during a badminton play. He was injured when he attempted to receive a high serve. The shuttlecock came to his left, so he stepped his right foot to the left first and jump to hit it. However, he felt pain at the left lower extremity when his left foot landed on the ground and immediately lost the ability to continue the play. He denied a direct impact injury to the proximal end of the left leg and confirmed no history of trauma or surgical treatment on the lower extremity.\nPhysical examination revealed no obvious deformity and intact skin of the left leg with mild tenderness upon palpation of the lateral malleolus, as well as the proximal aspect of the fibula. Medial or posterior tenderness was not presented. The initial motions of the ankle joint were limited and there was no distal neurovascular deficit. There were no other skeletal injuries and the systemic examination was unremarkable.\nPlain radiographs demonstrated a spinal fracture at the proximal fibula with no displacement of fragments. Evidence of a medial, lateral, or posterior malleolar fracture or other defects was not clear . Talar shift or widening of the ankle mortise was not noted.\nComputed tomography (CT) images of the ankle showed an avulsion fracture of the anterior tibia by the anterior inferior tibiofibular ligament (AITFL) with a nondisplaced bony fragment . However, magnetic resonance images suggested no injury of the posterior inferior tibiofibular ligament, interosseous tibiofibular ligament, deltoid ligament, and both the medial and lateral malleoli .\nConsidering the ankle was stable, we decided to perform nonoperative management. The injury was treated with rest, ice, and elevation. Immobilization of the left lower leg was done with a short leg cast for 6 weeks. Six weeks later, the cast was removed. After that, gradual resumption of ankle range of motion, leg strengthening exercises, and regular activities began. The patient initially walked with hand support. Three months after the injury, the patient started to walk with full body weight. The patient presented free of pain, good ankle motion, and functional recovery during follow-ups at 6 weeks, 3 months, and 6 months after the injury. Plain radiographs showed successful recovery of the fracture at the proximal fibula . At the final follow-up, his American Orthopaedic Foot and Ankle Society ankle-hindfoot (AOFAS) score was 100 out of 100 total points, and he returned to his regular sport, badminton.", "summary": "A 48-year-old male reported pain in the lateral part of his left lower leg and ankle during a badminton play. Physical examination revealed tenderness and swelling of the lateral aspects of the left ankle, as well as the proximal aspect of the fibula. Preoperative plain x-ray image, computed tomography, and magnetic resonance imaging revealed an avulsion fracture of the anterior tibia by the anterior inferior tibiofibular ligament without medial and posterior fracture, rupture of the deltoid ligament, or interosseous membrane. Nonoperative management was performed and successful recovery was observed at a 6-month follow-up.", "subclaim_evaluations": [ { "subclaim": "The patient is a 48-year-old male.", "support_label": "supported" }, { "subclaim": "The patient reported pain in the lateral part of his left lower leg.", "support_label": "supported" }, { "subclaim": "The patient reported pain in the lateral part of his left ankle.", "support_label": "supported" }, { "subclaim": "The pain occurred during badminton play.", "support_label": "supported" }, { "subclaim": "Physical examination revealed tenderness of the lateral aspects of the left ankle.", "support_label": "supported" }, { "subclaim": "Physical examination revealed swelling of the lateral aspects of the left ankle.", "support_label": "not_supported" }, { "subclaim": "Physical examination revealed tenderness of the proximal aspect of the fibula.", "support_label": "supported" }, { "subclaim": "Preoperative plain x-ray image showed an avulsion fracture of the anterior tibia.", "support_label": "not_supported" }, { "subclaim": "The avulsion fracture was caused by the anterior inferior tibiofibular ligament.", "support_label": "supported" }, { "subclaim": "There was no medial fracture.", "support_label": "supported" }, { "subclaim": "There was no posterior fracture.", "support_label": "supported" }, { "subclaim": "There was no rupture of the deltoid ligament.", "support_label": "supported" }, { "subclaim": "There was no rupture of the interosseous membrane.", "support_label": "supported" }, { "subclaim": "Nonoperative management was performed.", "support_label": "supported" }, { "subclaim": "Successful recovery was observed at a 6-month follow-up.", "support_label": "supported" } ] }, { "id": "multiclinsum_test_1374_en.txt", "fulltext": "An 87-year-old Asian woman in good general health presented with a progressively enlarging mass located in her left preauricular region. Fine needle aspiration (FNA) cytology analysis performed in the clinic suggested malignant cells of uncertain origin, but the tumors showed a rapid and consistent regression after FNA. During six months of observation, the tumor regrew and the patient was referred to our hospital.\nA physical examination revealed a 55-mm tumor located in the parotid with extension to the retroparotid area, and swelling of her left laterocervical lymph node. A computed tomography scan showed a peripheral enhanced mass in her right parotid gland. Magnetic resonance imaging revealed low signal intensity on T1-weighted images and iso-high signal intensity on T2-weighted images. The images showed the lesion to be clearly circumscribed, with homogeneous hypo-iso signal intensity on T1-weighted images and heterogeneous high signal intensity on T2-weighted images. The tumor demonstrated circumscribed and heterogeneous enhancement on gadolinium-enhanced T1-weighted images . Computed tomography scans of her thorax and abdomen did not reveal involvement of other sites.\nFNA was performed again and a cytological examination revealed a Papanicolaou classification of Class V, suggesting SmCC. A total parotidectomy and modified neck dissection were performed. On histopathology, the tumor showed diffuse growth with confluent necrosis in the salivary gland. The tumor cells had scant cytoplasm and hyperchromatic nuclei without prominent nucleoli. Mitotic figures were frequently observed . Neoplasmic elements reveal positivity for cluster of differentiation 56, neuron specific enolase, synaptophysin and a dotted staining pattern with cytokeratin 20 . Based on our histopathological findings, a diagnosis of a Merkel-cell-like SmCC of the parotid gland was made. Additional studies were positive for Maspin.\nOur patient’s postoperative course was uneventful, and no postoperative radiotherapy was administered. The nine-year clinical follow-up, which is the longest follow-up of head and neck SmCC in our knowledge, revealed no locoregional recurrence or distant metastasis.", "summary": "We present a locoregional advanced parotid small cell carcinoma with multiple lymph node metastases in an 87-year-old Asian woman. The tumor was controlled by surgery alone, and nine-year disease-free survival was achieved without any adjunctive therapy. To the best of our knowledge, this is the longest reported follow-up of head and neck small cell carcinoma.", "subclaim_evaluations": [ { "subclaim": "The patient is an 87-year-old Asian woman.", "support_label": "supported" }, { "subclaim": "The patient has locoregional advanced parotid small cell carcinoma.", "support_label": "supported" }, { "subclaim": "The patient has multiple lymph node metastases.", "support_label": "not_supported" }, { "subclaim": "The tumor was controlled by surgery alone.", "support_label": "supported" }, { "subclaim": "Nine-year disease-free survival was achieved.", "support_label": "supported" }, { "subclaim": "No adjunctive therapy was used.", "support_label": "supported" }, { "subclaim": "This is the longest reported follow-up of head and neck small cell carcinoma.", "support_label": "supported" } ] }, { "id": "multiclinsum_test_2715_en.txt", "fulltext": "A 23-year-old woman was referred to our hospital because of recurrent abdominal pain for 7 years, amenorrhea and dyspareunia. The patient’s mental state and movement ability was normal. She had a history of fracture of both legs and skin injury of pubic caruncle caused by trauma about 20 years ago.\nGynecological examination showed the patient had a single orifice on the urogenital region located where the urethra would be expected. There is a normally located anal perineal orifice. When forced urination, urine flowed out of the single orifice on the urogenital region. The urethral catheter was inserted about 70 mm through the single orifice, and no urine flowed out.\nPelvic CT scan showed a large calculus and a urethral catheter in the vagina . Pelvic MRI scan demonstrated the urethra and the vagina merged into a common channel about 3.45 cm long , and a large calculus about 7.8 cm × 6.8 cm × 7.7 cm in size lodging in the upper vagina, the uterus was moved upward ; a urethral catheter entered the vagina through the opening on the urogenital region; both ovaries and bladder were normal and no other congenital malformation was noted . Transabdominal sonography imaging revealed a vaginal stone, and normal two kidneys, the bladder, uterus, cervix, and adnexa.\nUnder general anesthesia, entering the urogenital tract through the median perineum approach and a 2-cm incision was performed . A hard grayish-yellow abnormal mass was observed in the vaginal cavity , and there was no adhesion to the surrounding mucosa. The tissue around the calculus was carefully separated and the calculus was completely removed.\nDuring the exploration after lithotomy, the common channel formed by vagina and urethra was detected, and the orifice of urethra was about 3 cm from the anterior vault of the vagina. The urethral catheter was inserted about 20 mm through the orifice of urethra, the urine flow was observed. Therefore, the estimated length of the urethra was about 2 cm. Hysteroscopic insertion of the vagina revealed thin endometrium and normal cervix, no other abnormality was found. The patient was diagnosed with a vaginal stone, urogenital sinus anomaly and thin endometrium.\nVaginal reconstruction (vaginoplasty) and urethra reconstruction (urethroplasty) were performed. The mucosa near the urethral orifice was taken and wrapped by 20 fr Foley’s catheter, forming a urethra about 4 cm and neourethral meatus. The vaginal mucosa was pulled down and intermittently sutured with the perineal skin to form a vagina about 8 cm that could hold two fingers.\nAfter the operation, the patient received the treatment of estrogen and progesterone, and menarche appeared 20 days later. One month after the operation, the patient recovered well, and could urinate by himself. After 8 months of follow-up, the patient had normal menstruation and urination. The patient is married and ready to conceive.", "summary": "We present a case of a 23-year-old woman with urogenital sinus anomaly who presented with a vaginal calculus. The patient was not suspected of a calculus in the vagina until the patient suffered amenorrhea and dyspareunia. Pelvic computed tomography (CT) and magnetic resonance imaging (MRI) confirmed the patient had urogenital sinus anomaly with vaginal calculus. For the reason, the calculus was removed by surgery, and the reconstruction of vagina and urethra was performed. The postoperative recovery and follow-up were uneventful.", "subclaim_evaluations": [ { "subclaim": "The patient is a 23-year-old woman.", "support_label": "supported" }, { "subclaim": "The patient has a urogenital sinus anomaly.", "support_label": "supported" }, { "subclaim": "The patient presented with a vaginal calculus.", "support_label": "supported" }, { "subclaim": "The patient had amenorrhea.", "support_label": "supported" }, { "subclaim": "The patient had dyspareunia.", "support_label": "supported" }, { "subclaim": "Pelvic CT was performed.", "support_label": "supported" }, { "subclaim": "Pelvic MRI was performed.", "support_label": "supported" }, { "subclaim": "The imaging confirmed urogenital sinus anomaly.", "support_label": "supported" }, { "subclaim": "The imaging confirmed the presence of a vaginal calculus.", "support_label": "supported" }, { "subclaim": "The calculus was removed by surgery.", "support_label": "supported" }, { "subclaim": "Vaginal reconstruction was performed.", "support_label": "supported" }, { "subclaim": "Urethral reconstruction was performed.", "support_label": "supported" }, { "subclaim": "The postoperative recovery was uneventful.", "support_label": "supported" }, { "subclaim": "The follow-up was uneventful.", "support_label": "supported" } ] }, { "id": "multiclinsum_test_497_en.txt", "fulltext": "A 48-year-old woman was admitted to the emergency department with sudden onset severe chest tightness whilst doing yoga. This was associated with pins and needles in both arms, nausea, and abdominal discomfort. It lasted for 1 hour before it self-resolved and was not related to exertion. She reported being under increased emotional stress in the preceding month prior to presentation. She had no significant past medical history and was not on any regular medications.\nShe had a mother who died suddenly from an ascending aortic dissection in her 50s. Her mother was not hypertensive and suffered no symptoms or comorbidity suggestive of systemic illness.\nThe patient was hypotensive with a blood pressure of 90/60 mmHg and a heart rate of 80 bpm with no respiratory compromise or fever. Her troponin I (high-sensitivity assay) was 54 ng/dl, 79 ng/dl, and 27 ng/dl, respectively. Her electrocardiogram (ECG) showed sinus bradycardia with no ischaemic changes. A CT pulmonary angiogram was performed and excluded pulmonary embolus and showed no other cause for chest pain. An echocardiogram showed preserved biventricular function with no significant valvulopathy and normal ascending aorta dimensions. A coronary angiogram performed on day 2 of admission showed type 1 distal left anterior descending (LAD) coronary artery dissection with thrombolysis in antiplatelets and myocardial infarction (TIMI) 3 flow . She was initially managed with fondaparinux (factor Xa inhibitor) and dual antiplatelets with low-dose beta blocker long term once spontaneous coronary artery dissection (SCAD) was confirmed.", "summary": "This case report describes a 48-year-old woman suffering from SCAD who had a mother who died from ascending aortic dissection in her 50s.", "subclaim_evaluations": [ { "subclaim": "The patient is a 48-year-old woman.", "support_label": "supported" }, { "subclaim": "The patient has spontaneous coronary artery dissection (SCAD).", "support_label": "supported" }, { "subclaim": "The patient's mother died from ascending aortic dissection.", "support_label": "supported" }, { "subclaim": "The patient's mother died in her 50s.", "support_label": "supported" } ] }, { "id": "multiclinsum_test_1734_en.txt", "fulltext": "A 75-year-old man with a history of persisting abdominal pain and mild diarrhoea for three months was referred by a general practitioner to the hospital. During this period the patient observed a weight loss of 2 kg, but did not show any B symptoms. A colonoscopy was performed without pathological findings. A subsequent CT examination of the abdomen showed two separate fat-containing retroperitoneal masses one in the adrenal gland and the second lateral of the psoas muscle inferior to the right kidney, outside the peri-renal adipose tissue. The lesions were separate and had no connecting tissue in between them . To further confirm the obtained CT scan results an MR imaging was performed and showed again a fat-containing lesion in the adrenal gland and a 7 × 5 × 7 cm soft tissue-tumour inferior to the right kidney without invasion of the right kidney, urethra or renal vasculature. Both lesions appeared similar in the CT and MR imaging and were consistent with a well-differentiated liposarcoma . Aware of the fact that a liposarcoma of the adrenal gland is extremely rare, a primary benign and fat containing tumour derived from the adrenal gland itself, such as a lipoma or myelolipoma was considered. Regarding tumour markers, only increased levels of CA 19-9 were detected (81.86 U/ml reference < 37 U/ml, CEA 2.2 μg/l, reference < 5 μg/l). To exclude a neuroendocrinological pathology additional tests were performed but did not reveal any noticeable conspicuities.\nConsequently, we assumed a combination of a retroperitoneal liposarcoma and a primary benign, lipomatous tumour of the adrenal gland. Alternatively, the very rare case of the combination of a retroperitoneal liposarcoma and an adrenal liposarcoma was taken into consideration. Therefore, two therapeutic options were considered on these accounts. In the unlikely case of simultaneous liposarcomas an enbloc resection including both masses would be required after pre-treatment. But, in the probable situation of a benign lipomatous primary lesion of the adrenal gland in combination with a retroperitoneal liposarcoma an adrenalectomy with an additive biopsy of the infrarenal mass was decided as the strategy of choice in this individual case.\nConcerning this strategy a neoadjuvant radiotherapy followed by radical surgery, preventing the kidney, could have been performed as it has been approved as follows. To perform a neoadjuvant therapy a positive biopsy for sarcoma would be a compulsory prerequisite. Prognostic survival markers for retroperitoneal liposarcomas are the histologic subtype and margin of resection . Response rates to neoadjuvant chemotherapy alone are less than 10% . Preoperative radiation therapy or combined radio-chemotherapy with consecutive radical resection improves survival [,]. Concerning surgery complete resection of the lesion is to be achieved. Extended resection including contiguous organs without pre-treatment is associated with an increased risk without influence on disease specific survival and is therefore considered to be inappropriate .\nAccording to our described strategy, the patient received a laparotomy. As expected, the adrenal tumour appeared well-encapsulated in accordance with a benign lipomatous tumour. Following the above mentioned second option first an adrenalectomy was performed. The rapid section of the adrenal lesion revealed the result of a myelolipoma. Having in mind that both lesions presented morphologically identical in CT and MR imaging and the assessed intraoperatively analogousness of the masses, we resigned a biopsy of the infrarenal tumour and removed it in toto without the kidney. Once more the rapid section revealed a myelolipoma. The final histology described a 4 cm sized and in weight 46 g well-encapsulated myelolipoma of the adrenal gland. Further a 14 cm sized and in weight 250 g well-encapsulated retroperitoneal myelolipoma was determined, without capsule involvement. Both tumours were composed of predominantly mature adipose tissue with mature myeloid elements, allowing the diagnosis of an extra-adrenal and adrenal myelolipoma. Consequently no other treatment than surgery was indicated and has not been performed in this case.\nPostoperatively, the patient's recovery was uneventful and he was subsequently discharged.", "summary": "We report a very seldom case of a simultaneous myelolipoma of the adrenal gland in association with an extra-adrenal myelolipoma in an 75-year-old man. With a review of the literature we describe and discuss the aetiology, differential diagnosis and treatment of patients with respect to adrenal and extra-adrenal lesions.", "subclaim_evaluations": [ { "subclaim": "The case involves a 75-year-old man.", "support_label": "supported" }, { "subclaim": "The patient had a myelolipoma of the adrenal gland.", "support_label": "supported" }, { "subclaim": "The patient also had an extra-adrenal myelolipoma.", "support_label": "supported" }, { "subclaim": "The coexistence of adrenal and extra-adrenal myelolipomas is very seldom.", "support_label": "supported" }, { "subclaim": "The report includes a review of the literature.", "support_label": "not_supported" }, { "subclaim": "The report discusses the aetiology of adrenal and extra-adrenal myelolipomas.", "support_label": "not_supported" }, { "subclaim": "The report addresses the differential diagnosis of adrenal and extra-adrenal myelolipomas.", "support_label": "supported" }, { "subclaim": "The report discusses the treatment of adrenal and extra-adrenal myelolipomas.", "support_label": "supported" } ] }, { "id": "multiclinsum_test_1478_en.txt", "fulltext": "In April 2017, a 72-year-old homeless male patient was admitted to the emergency department at the Ramos Mejia Hospital, Ciudad Autónoma de Buenos Aires, Argentina. The patient was in very poor hygienic condition, malnourished and dehydrated. He presented a deep necrotic ulcer in the anterior aspect of his left tibia of 9-months’ evolution, with exposure of both tibia and fibula, complete loss of muscle mass, severe ischaemia, foul discharge and heavy burden myiasis. Unfortunately, maggots had been rapidly discarded, allowing neither bacterial analysis nor entomological identification.\nThe patient had a history of alcohol abuse and pulmonar tuberculosis in 1980 which resolved after complete treatment.\nOn physical examination, his blood pressure was 100/60 mmHg, his heart rate 97 and his respiratory rate 20 breaths min−1. His body temperature was 36 °C. Haematological and biochemical exams on admission showed: leucocytes 24750 K µl−1, with 92.5 % neutrophils; glucose level of 237 mg dl−1, haematocrit 40 %, haemoglobin 13.3 g dl−1, uraemia 126 mg dl−1, creatinine 2017 mg dl−1; sodium 127 mmol l−1; potassium 5.5 mmol l−1; chloride 87 mmol l−1.\nTwo blood culture sets were taken at the time of admission, at two different times. Gram-negative rods were obtained in pure culture. With this preliminary report, the case was described as sepsis caused by skin and soft tissue infection. Intravenous therapy with ciprofloxacin 400 mg/12 h and clindamicin 600 mg/12 h was initiated.\nConventional phenotypic test and MALDI-TOF-MS (Bruker Daltonics) failed to identify the bacteria isolated.\nIn order to confirm genus and species identification, PCR amplification of the 16S rRNA was performed. The nearly complete sequence of the 16S rRNA gene was amplified by PCR with the conserved primers 8F (5′-AGAGTTTGATYMTGGCTCAG-3′) and 1942R (5′-ACCTTGTTACGACTT-3′), as described previously . The sequence obtained showed a 100 % identity with the sequence corresponding to the 16S RNA ribosomal gene of I. indica, type strain FFA1 (GenBank accession number. EU008088.2). The 16S rRNA sequence obtained was deposited in GenBank under number MF062521.\nDue to the severity of the lesions, a supracondylar amputation had to be performed in order to allow for adequate and prompt infection source control, and antibiotic treatment for 14 days was completed, which led to resolution of sepsis and normalization of laboratory parameters. The patient had a favourable outcome, with no surgical complications.\nMembers of the genus Ignatzschineria are difficult to identify using traditional methods, including classical biochemical tests and commercial bacterial identification systems. Even MALDI-TOF MS analysis has been unsuccessful. 16S ARNr gene sequencing has proved to be useful for identification, and is currently the most accurate method for clinical diagnostic laboratories.", "summary": "We report the first case of sepsis associated with complicated skin and soft tissue infection caused by I. indica in Latin America.", "subclaim_evaluations": [ { "subclaim": "The case reported is the first in Latin America.", "support_label": "not_supported" }, { "subclaim": "The infection was associated with sepsis.", "support_label": "supported" }, { "subclaim": "The infection was a complicated skin and soft tissue infection.", "support_label": "supported" }, { "subclaim": "The causative organism was I. indica.", "support_label": "supported" } ] }, { "id": "multiclinsum_test_2911_en.txt", "fulltext": "A 59-year-old white European man with a history of epilepsy, treated with valproic acid and carbamazepine, was admitted to our emergency department for a serious head injury after falling down the stairs at home. His family contacted our emergency department soon after the accident. An initial medical examination found a Glasgow Coma Scale (GCS) of 9/15 with no pupillary defect. His heart rate was 50 beats per minute. His blood pressure was 100/50 mmHg and his blood oxygen was 80 %.\nHe underwent orotracheal intubation and vascular filling. A clinical examination revealed a large scalp wound, which was responsible for a significant blood loss, which continued until his arrival at our hospital despite a compression bandage. He was transferred to our emergency neurosurgery unit.\nOn admission, he underwent a vascular filling (1.0 L of saline). A neurological examination found a GCS of 3/15 and his pupils were intermediate, symmetric, and reactive. The admission laboratory tests, summarized in Table , showed anemia, thrombocytopenia, hypoproteinemia and coagulation disorders.\nA brain scan without contrast (performed 2 hours after his head injury) showed an isodense, extracerebral, homogeneous SDH, 40 Hounsfield units (HU) approximately, with an estimated maximum thickness of 20 mm, situated along the right convexity . There was also a subarachnoid hemorrhage in the fold of the left convexity . The SDH had a mass effect with a 15 mm deviation of midline structures to the left and cerebral compression. In the bone window, the scan showed multiple fractures of the cranial vault in the layers above and below . This initial damage assessment revealed no other lesions. The patient became hypotensive. His blood pressure was 70/40 mmHg. He underwent hemodynamic support by continuous administration of norepinephrine (1 mg/hour) associated with 1.0 L of saline and 500 mL of Gelafundin (succinylated gelatin). Four units of packed red blood cells were administered with six units of fresh frozen plasma.\nHe was immediately transferred to our operating room. A burr hole was first drilled through his right parietal bone to assess the consistency of the hematoma and relieve the cerebral compression as quickly as possible. Correction of coagulation disorders was carried out at the same time by our anesthetists. Fresh blood mixed with clots flowed through the burr hole, thus confirming the acute nature of the hematoma.\nIn order to evacuate the hematoma, the incision was extended to carve a frontotemporoparietal flap giving access to the entire convexity and confirming the clotted appearance of the acute SDH. The flap was not put back in place when closing due to a life-threatening cerebral edema.\nHe was admitted to our neurosurgical intensive care unit. The evolution was marked by the appearance of intracranial hypertension, which was refractory to medical treatment and led to the appearance of clinical signs of encephalic death, which was confirmed 72 hours after admission to our intensive care unit.", "summary": "We report the case of a 59-year-old white European man who had a serious head injury with an acute subdural hematoma. The trauma was also responsible for blood loss and hemostasis disorders. A cerebral computed tomography scan revealed an isodense subdural hematoma. Our intervention confirmed that it was an acute hematoma.", "subclaim_evaluations": [ { "subclaim": "The patient is a 59-year-old white European man.", "support_label": "supported" }, { "subclaim": "The patient had a serious head injury.", "support_label": "supported" }, { "subclaim": "The patient had an acute subdural hematoma.", "support_label": "supported" }, { "subclaim": "The trauma caused blood loss.", "support_label": "supported" }, { "subclaim": "The trauma caused hemostasis disorders.", "support_label": "supported" }, { "subclaim": "A cerebral computed tomography scan was performed.", "support_label": "supported" }, { "subclaim": "The computed tomography scan showed an isodense subdural hematoma.", "support_label": "supported" }, { "subclaim": "The subdural hematoma was confirmed to be acute.", "support_label": "supported" } ] }, { "id": "multiclinsum_test_3323_en.txt", "fulltext": "The case report was approved by the Ethics Committee of the General Hospital of Veroia (decision No. 11, 10/12/2017). The patient’s family provided verbal informed consent. A 64-year-old man with a medical history of bipolar disorder and arterial hypertension was hospitalized for a delayed presentation ST-elevation myocardial infarction. He was admitted to our hospital 24 hours after symptom onset. Diagnostic coronary angiography revealed 95% stenosis at the distal third of the right coronary artery, and he underwent a primary percutaneous coronary intervention to the culprit lesion. Loading doses of aspirin and ticagrelor were given. During his hospitalization, he reported palpitations and shortness of breath. Clinical examination revealed normal heart sounds and a grade III systolic murmur at the cardiac apex. The patient’s blood pressure was 100/65 mmHg, pulse rate was 95 bpm, and respiratory rate was 14 breaths/minute. He had functional class II heart failure according to the New York Heart Association. Electrocardiography showed a sinus rhythm with Q-wave formation in the inferior wall leads (II, III, aVF), T-wave inversion in the same leads, and borderline QT prolongation (QTc of 490 ms). No ST elevation suggestive of left ventricular aneurysm formation was noticed. The P2Y12 inhibitor was switched from ticagrelor to prasugrel, and 24-hour ambulatory electrocardiography revealed frequent premature atrial and ventricular complexes. Transthoracic echocardiography showed a hypokinetic posteroinferior wall with a mildly reduced ejection fraction of 45% (Simpson’s method), moderate mitral regurgitation (vena contracta, 0.6 cm; proximal isovelocity surface area, 0.7 cm; effective regurgitant orifice area, 34 mm2), and mild pericardial effusion.\n\nFurosemide was added to lisinopril and metoprolol, but only mild to moderate improvement of the patient’s symptoms was noticed before he deteriorated. Furthermore, up-titration of these medications was difficult because of the borderline arterial pressure. The addition of ivabradine and the switch from ticagrelor to prasugrel did not change his clinical status. Ticagrelor may cause transient dyspnea in some patients, which reverses with discontinuation.3\n\nForty days after the myocardial infarction, the patient was readmitted because of exertional dyspnea and worsening shortness of breath. New transthoracic echocardiography showed a dyskinetic cavity that was connected to the posteroinferior wall and communicated with the left ventricle, causing damage to the posterior mitral valve leaflet (P1 scallop) and resulting in severe mitral regurgitation. A color Doppler study confirmed passage of blood from the left ventricle into the cavity through an opening in the left ventricular wall. No thrombus formation was detected. The diagnosis of left ventricular pseudoaneurysm was made.\n\nUnfortunately, the patient died while waiting to transfer for surgical treatment.", "summary": "A 64-year-old man with a history of bipolar disorder and arterial hypertension was hospitalized for delayed presentation ST-elevation myocardial infarction. He was admitted to our hospital 24 hours after symptom onset. Diagnostic coronary angiography revealed 95% stenosis at the distal third of the right coronary artery, and he underwent a primary percutaneous coronary intervention to the culprit lesion. Despite administration of a diuretic and optimization of other pharmaceutical treatment, his heart failure deteriorated. Electrocardiography showed a sinus rhythm with Q-wave formation in the inferior wall leads (II, III, aVF), T-wave inversion in the same leads, and borderline QT prolongation (QTc of 490 ms). No ST elevation suggestive of left ventricular aneurysm formation was noticed. Forty days later, cardiac ultrasound revealed a dyskinetic cavity (pseudoaneurysm) in continuity with the posterior–inferior wall of the myocardium, resulting in severe mitral valve regurgitation. Unfortunately, the patient died while awaiting surgical treatment.", "subclaim_evaluations": [ { "subclaim": "The patient is a 64-year-old man.", "support_label": "supported" }, { "subclaim": "He has a history of bipolar disorder.", "support_label": "supported" }, { "subclaim": "He has a history of arterial hypertension.", "support_label": "supported" }, { "subclaim": "He was hospitalized for delayed presentation ST-elevation myocardial infarction.", "support_label": "supported" }, { "subclaim": "He was admitted 24 hours after symptom onset.", "support_label": "supported" }, { "subclaim": "Diagnostic coronary angiography revealed 95% stenosis at the distal third of the right coronary artery.", "support_label": "supported" }, { "subclaim": "He underwent a primary percutaneous coronary intervention to the culprit lesion.", "support_label": "supported" }, { "subclaim": "Electrocardiography showed Q-wave formation in the inferior wall leads (II, III, aVF).", "support_label": "supported" }, { "subclaim": "Electrocardiography showed T-wave inversion in the inferior wall leads.", "support_label": "supported" }, { "subclaim": "The QTc was 490 ms.", "support_label": "supported" }, { "subclaim": "No ST elevation suggestive of left ventricular aneurysm formation was noticed.", "support_label": "supported" }, { "subclaim": "Forty days later, cardiac ultrasound revealed a dyskinetic cavity in continuity with the posterior–inferior wall of the myocardium.", "support_label": "supported" }, { "subclaim": "The dyskinetic cavity was diagnosed as a pseudoaneurysm.", "support_label": "supported" }, { "subclaim": "The pseudoaneurysm resulted in severe mitral valve regurgitation.", "support_label": "supported" }, { "subclaim": "The patient died while awaiting surgical treatment.", "support_label": "supported" } ] }, { "id": "multiclinsum_test_1332_en.txt", "fulltext": "Following a right radical orchidectomy and four cycles of chemotherapy for a metastatic non-seminomatous germ cell tumor of the testis, our patient, a 21-year-old man of Caucasian origin, underwent RPLND for a residual mass. The procedure was prolonged and in order to achieve complete surgical excision, a right radical nephrectomy and excision of the inferior vena cava from the iliac veins to the level of the left renal vein was necessary due to tumor infiltration and encasement.\nThree days postoperatively, the patient developed bilateral leg pain, lower limb oedema and abdominal distension secondary to abdominal ascites . This continued to worsen and on day nine postoperatively, he developed a paralytic ileus, pleural effusions and respiratory failure, and was transferred to the intensive care unit for elective intubation, ventilatory support and chest tube drainage of the pleural effusions .\nWith fears that our patient would develop intra-abdominal compartment syndrome and that the respiratory compromise would be worsened, a 12 Fr pigtail drainage catheter was inserted under ultrasound guidance on postoperative day 22 into the abdominal cavity, immediately producing 11 litres of chylous fluid. Shortly after a drain was inserted, the respiratory compromise improved and the patient was extubated. The drain continued to maintain an output of six liters per day for a further four days before settling to an average output of between two and three liters per 24 hours. Conservative management consisted of a parenteral diet of medium chain triglycerides, diuretic therapy and 20% albumin three times a day. Daily intraperitoneal infusion of 200 mls of the water-soluble contrast medium Conray 280 mg I/ml (Iothalamate meglumine) in order to promote peritoneal lymphatic fibrosis was attempted but produced no real improvement. Blockage of the intra-abdominal drain necessitated its replacement on two separate occasions.\nOn day 41, the patient was discharged to the ward where he maintained this improvement. Total parenteral nutrition was commenced to supplement poor oral intake. The patient had also developed bilateral foot drop on day 22 postoperatively. This was felt to be due to pedal oedema compressing each peroneal nerve at the head of fibula. It improved gradually with resolving peripheral oedema and physiotherapy. He was discharged to a peripheral hospital for further care on day 53, with an average output of 1.5 liters. Histologically, all the resected retroperitoneal tissue was free from residual tumor and contained only lymphoid tissue with large areas of necrosis.", "summary": "We describe a 21-year old man of Caucasian origin who had metastatic non-seminomatous germ cell tumor of the testis, and underwent retroperitoneal lymph node dissection, nephrectomy and partial inferior vena cava excision for a residual mass. The patient subsequently developed persistent lymphatic drainage causing foot drop that eventually responded to conservative medical and surgical measures.", "subclaim_evaluations": [ { "subclaim": "The patient is a 21-year-old man.", "support_label": "supported" }, { "subclaim": "The patient is of Caucasian origin.", "support_label": "supported" }, { "subclaim": "The patient had metastatic non-seminomatous germ cell tumor of the testis.", "support_label": "supported" }, { "subclaim": "The patient underwent retroperitoneal lymph node dissection.", "support_label": "supported" }, { "subclaim": "The patient underwent nephrectomy.", "support_label": "supported" }, { "subclaim": "The patient underwent partial inferior vena cava excision.", "support_label": "supported" }, { "subclaim": "The surgeries were performed for a residual mass.", "support_label": "supported" }, { "subclaim": "The patient developed persistent lymphatic drainage.", "support_label": "supported" }, { "subclaim": "The persistent lymphatic drainage caused foot drop.", "support_label": "not_supported" }, { "subclaim": "The foot drop eventually responded to conservative medical and surgical measures.", "support_label": "supported" } ] }, { "id": "multiclinsum_test_2304_en.txt", "fulltext": "A 7-year-old Japanese boy was referred to our hospital because of painless swelling of the bilateral inguinal lymph nodes which had gradually increased for 7 months. His past medical history included atopic dermatitis, and his family history included type 1 diabetes mellitus in his mother. Hematological examination showed the following abnormal values: soluble interleukin-2 receptor, 2,599 U/mL; and immunoglobulin E, 568 IU/mL. A biopsy of a left inguinal lymph node lead to the diagnosis of Hodgkin lymphoma (nodular lymphocyte predominant type). Fluoro-18 fluorodeoxyglucose-positron emission tomography (F-18 FDG PET)/computed tomography (CT) showed a high accumulation (maximum standardized uptake value, SUVmax) at 17.02 in the left common iliac lymph node, left external and internal iliac nodes, and left inguinal lymph node. On the basis of the F-18 FDG PET/CT results and B symptoms, such as weight loss and night sweats, the final staging was determined to be IIB. The patient underwent chemotherapy according to the protocol of the EuroNet-PHL-C1 protocol with 2 cycles of the OEPA regimen (vincristine, etoposide, prednisone, and doxorubicin) and 2 cycles of the COPDAC regimen (cyclophosphamide, vincristine, prednisone, and dacarbazine). Chemotherapy was to be followed by radiotherapy at a dose of 19.8 Gy (11 fractions of 1.8 Gy per day) focused on residual lymph node lesions.\nTwo days after the end of the first cycle of the COPDAC regimen, the patient complained of headache and of blurred and decreased vision in both eyes. The first ophthalmologic examination showed a corrected visual acuity of 20/32 in the right eye and 20/40 in the left eye. Intraocular pressure could not be measured in the right eye and was 15 mmHg in the left eye. The anterior chamber depth was normal, with no evidence of inflammatory cells in the anterior chamber. Posterior ocular findings showed swelling of the optic nerve papillae in both eyes and serous retinal detachment. . Optical coherence tomography (OCT; Carl Zeiss Meditec AG) showed significant serous retinal detachment in the macular area and significant swelling of the optic nerve papillae in both eyes. Fluorescein angiography of the fundus showed fluorescent leakage from the optic nerve papilla in the early phase and petechial fluorescent leakage in both eyes . Indocyanine green angiography showed hypofluorescent dark dots in both eyes in the early phase . Ruled out as causes of a possible infectious uveitis via immunological examination were hepatitis B, hepatitis C, syphilis, and human T lymphotropic virus type 1, and ruled out via DNA analysis were herpes simplex virus, varicella-zoster virus, and cytomegalovirus. Cerebrospinal fluid examination revealed an increased cell count. Moreover, human leukocyte antigen (HLA)-DR4 was positive. Because the patient fulfilled items 1 to 4 of the revised diagnostic criteria proposed by the International Workshop on VKH , incomplete-type VKH disease was diagnosed.\nTo treat the VKH disease, the patient received steroid treatment with intravenous prednisolone 60 mg/m2/day for 7 days. After improvements in visual acuity and serous retinal detachment were confirmed, 1 cycle of the COPDAC regimen with the dosage increasing from 40 mg/m2/day to 60 mg/m2/day was started. Prednisolone (60 mg/m2/day) was administered for a total of 20 days. Thereafter, the administration of prednisolone was changed from intravenous to oral, after which the dose was gradually tapered. The minimum visual acuity before treatment was 20/400 in the right eye and 20/63 in the left eye. After 22 days of treatment with prednisolone, the visual acuity had improved to 20/20 in the right eye and 20/25 in the left eye, and the intra-anterior chamber inflammation and serous retinal detachment in the macula had disappeared. The steroid treatment was changed to hydrocortisone on day 65 after starting prednisolone. However, anterior chamber inflammation appeared on day 82 of steroid treatment, so the steroid treatment was changed to the dosage increased oral prednisolone again and dexamethasone eye drops were started. Subsequently, the flare-up of inflammation disappeared, and oral prednisolone and dexamethasone eye drops were discontinued.\nThe findings of OCT changed over the course of treatment . Serous retinal detachment was marked before treatment , but had disappeared after 21 days of steroid treatment . On day 43 of steroid treatment, visual acuity had improved, but irregular retinal pigment epithelial cells were observed . On day 82, when the intracameral inflammation flared up, the irregularity of retinal pigment epithelial cells worsened and continued .\nOne year after the diagnosis of Hodgkin lymphoma and 9 months after the diagnosis of VKH disease, multiple vitiligo appeared in the patient’s abdomen, and complete VKH disease was finally diagnosed. However, a sunset glow fundus was seen, but Sugiura sign was not. The patient has been doing well and has improved visual function, without evidence of recurrent Hodgkin lymphoma and VKH disease for 10 months after treatment with prednisolone had discontinued.", "summary": "The patient was a 7-year-old boy with stage IIB Hodgkin lymphoma (nodular lymphocyte predominant type) who was undergoing chemotherapy, including 2 cycles of the OEPA regimen and 1 cycle of the COPDAC regimen. Two days after the end of the COPDAC regimen, the patient complained of headache and of blurred and decreased vision in both eyes. On the basis of optic symptoms, such as uveitis and serous retinal detachment in both eyes, increased cell counts in cerebrospinal fluid, and positivity for human leukocyte antigen (HLA)-DR4 in peripheral blood cells, incomplete VKH disease was diagnosed. Intravenous treatment with high-dose prednisolone (60mg/m2/day) for 7 days improved both visual acuity and serous retinal detachment and enabled the remains of the COPDAC chemotherapy cycle to be administered. With prednisolone treatment, visual acuity improved from 20/500 to 20/20 in the right eye and from 20/63 to 20/25 in the left eye. Because multiple vitiligo lesions later appeared in the abdomen, complete VKH disease was finally diagnosed.", "subclaim_evaluations": [ { "subclaim": "The patient was a 7-year-old boy.", "support_label": "supported" }, { "subclaim": "The patient had stage IIB Hodgkin lymphoma.", "support_label": "supported" }, { "subclaim": "The Hodgkin lymphoma was nodular lymphocyte predominant type.", "support_label": "supported" }, { "subclaim": "The patient was undergoing chemotherapy.", "support_label": "supported" }, { "subclaim": "The patient received 2 cycles of the OEPA regimen.", "support_label": "supported" }, { "subclaim": "The patient received 1 cycle of the COPDAC regimen.", "support_label": "supported" }, { "subclaim": "Two days after the end of the COPDAC regimen, the patient complained of headache.", "support_label": "supported" }, { "subclaim": "Two days after the end of the COPDAC regimen, the patient reported blurred vision in both eyes.", "support_label": "supported" }, { "subclaim": "Two days after the end of the COPDAC regimen, the patient reported decreased vision in both eyes.", "support_label": "supported" }, { "subclaim": "The patient had uveitis in both eyes.", "support_label": "supported" }, { "subclaim": "The patient had serous retinal detachment in both eyes.", "support_label": "supported" }, { "subclaim": "The cerebrospinal fluid had increased cell counts.", "support_label": "supported" }, { "subclaim": "The patient had positivity for HLA-DR4 in peripheral blood cells.", "support_label": "supported" }, { "subclaim": "Incomplete VKH disease was diagnosed.", "support_label": "supported" }, { "subclaim": "The patient received intravenous high-dose prednisolone (60mg/m2/day) for 7 days.", "support_label": "supported" }, { "subclaim": "Visual acuity improved after prednisolone treatment.", "support_label": "supported" }, { "subclaim": "Serous retinal detachment improved after prednisolone treatment.", "support_label": "supported" }, { "subclaim": "The patient completed the remaining COPDAC chemotherapy cycle.", "support_label": "supported" }, { "subclaim": "Visual acuity in the right eye improved from 20/500 to 20/20.", "support_label": "not_supported" }, { "subclaim": "Visual acuity in the left eye improved from 20/63 to 20/25.", "support_label": "supported" }, { "subclaim": "Multiple vitiligo lesions later appeared in the abdomen.", "support_label": "supported" }, { "subclaim": "Complete VKH disease was finally diagnosed.", "support_label": "supported" } ] }, { "id": "multiclinsum_test_1287_en.txt", "fulltext": "A 4-year-old boy (height, 100 cm; weight, 16 kg) was hit in the chest by a car. He was conscious and complained of chest tightness. Upon arrival to the local hospital at 18 min after the injury, he was semiconscious and cyanotic. Breath sounds were not heard in the right hemithorax, and his vital signs were unstable: heart rate( HR) of 162 beats per minute (bpm), blood pressure (Bp) of 102/56 mmHg, respiratory rate (RR) of 32 times per minute, and oxygen saturation (SPO2) of 70%. For sedation, 30 mg of propofol was administered intravenously, and emergency endotracheal tube above the carina was performed. Chest computed tomography (CT) showed right pneumothorax with lung compression of 90%, and the left clavicle was fractured . A chest tube was positioned in the right thoracic cavity, and a breathing balloon was used for ventilation. His vital signs were as follows: HR of 155 bpm, Bp of 97/50 mmHg, RR of 22 times per minute, and SPO2 of 98%. Twenty-four minutes later, he was admitted to the Emergency Department of our hospital for further treatment. The results of blood gas analysis were as follows: pH, 7.12; carbon dioxide partial pressure (PaCO2), 76 mmHg; oxygen partial pressure (PaO2), 68 mmHg. Bronchoscopy indicated that the right middle lobe bronchus was ruptured. Transthoracic echocardiography ruled out associated blunt cardiac injury. Emergency exploratory thoracotomy and right middle or right middle and lower lobectomy were planned. The patient went into sudden cardiac arrest after being sent to the operating room (SPO2, 76%; end-tidal carbon dioxide partial pressure (PetCO2), 46 mmHg). Return of spontaneous circulation after twelve minutes of external chest compression. He did not regain consciousness. Mainstem intubation of the left bronchus was performed under direct fibreoptic guidance to ventilate the left lung. With pressure control ventilation, the fraction of inspiration O2 was 100%, peak pressure was 32 cmH2O, and tidal volume was 45 mL; HR was 145 bpm, Bp was 92/48 mmHg (0.05 µg/kg/min norepinephrine), RR was 20 times per minute, and SPO2 was 70%. Blood gas analysis results at this time were as follows: pH, 6.87; PaCO2, 114 mmHg; PaO2, 46 mmHg; plasma lactic acid (Lac), 6.7 mmol/L; K + , 3.2 mmol/L; haemoglobin 7.3 g/dl; and Ca + + 1.21 mmol/L. As sudden cardiac arrest occurred due to severe respiratory acidosis, we decided to initiate V-V ECMO. Our hospital has an adult ECMO centre, and it is 300 km away from our nearest paediatric ECMO centre, approximately a 3.5-h drive. To prevent death, we decided to use small adult ECMO tubes. ECMO was initiated percutaneously in the left femoral vein, and an incision was made in the right internal jugular vein (MAQUET 2050, Cardiopulmonary GmbH BE-PLS, Germany; left femoral vein: 15 Fr/5 mm single-stage drainage cannula, MAQUET, Germany; right internal jugular vein: 14 Fr/ZX 4.7 return cannula, Changzhou Kangxin Medical Equipment Co., Ltd., China). The blood flow was 1.7 L/min, sweep gas was 1.5 L/min, and FiO2 was 100%. Cardiac arrest occurred again after ECMO, and we immediately administered cardiopulmonary resuscitation. Blood gas analysis results at this time were as follows: pH, 6.84; PaCO2, 72 mmHg; PaO2, 61 mmHg; Lac, 9.7 mmol/L; K + , 9.8 mmol/L; haemoglobin 7.3 g/dl; and Ca + + 1.21 mmol/L. Insulin (2 U) were added to the glucose injection (10%, 100 ml), and sodium bicarbonate (5%, 32 ml) and calcium chloride injection (3%, 0.1 g) were administered immediately. Spontaneous sinus rhythm was restored after 18 min. An exploratory thoracotomy was performed successfully; the root of the right middle lobe bronchus was found to be ruptured , as was a branch of the right middle lobe artery. Right middle lobectomy and right middle bronchoplasty were performed. The patient was admitted to the intensive care unit (ICU) after the operation. Mechanical ventilation and ECMO were continued, and we adjusted the ventilator parameters as follows: FiO2 at 30%; positive end expiratory pressure (PEEP) at 10 cmH2O; respiratory rate at 12 times/minute, and tidal volume at 6 mL/kg. Oxygen saturation was between 98 and 100%. Along with mild hypothermia for brain protection (34-36 °C for 30 h), piperacillin sodium and tazobactam injection for the prevention of infection, methylprednisolone injection (16 mg q12 h) to reduce pulmonary exudation, and norepinephrine 0.15 µg/kg/min to maintain blood pressure were applied. On postoperative day 2, he became conscious and was responsive. Due to the traumatic wet lung on the left and secondary pulmonary infection, ECMO was withdrawn on the 6th day after the operation, with a total ECMO time of 137 h. Mechanical ventilation was withdrawn on postoperative day 11. On postoperative day 12, chest CT showed a mass of a high-density shadow in the upper lobe of the left lung with cavitation, which was considered a large traumatic pseudocyst . The patient left the ICU on postoperative day 16 and was discharged from the hospital on postoperative day 31 without neurological deficit. He is able to communicate and play normally. The timeline of the treatment process is shown in Fig. .", "summary": "A 4-year-old boy with bronchial rupture and traumatic wet lung complicated by cardiac arrest after chest trauma was admitted to an adult ECMO centre. He experienced two cardiac arrests, one before and one during the operation. The total duration of cardiac arrest was 30 min. V-V ECMO was initiated because of severe hypoxia and hypercapnia during the operation. ECMO was performed for 6 days, and mechanical ventilation lasted 11 days. On the 31st day after surgery, he had recovered completely and was discharged without neurological deficit.", "subclaim_evaluations": [ { "subclaim": "The patient is a 4-year-old boy.", "support_label": "supported" }, { "subclaim": "The patient had bronchial rupture.", "support_label": "supported" }, { "subclaim": "The patient had traumatic wet lung.", "support_label": "supported" }, { "subclaim": "The patient had cardiac arrest after chest trauma.", "support_label": "supported" }, { "subclaim": "The patient was admitted to an adult ECMO centre.", "support_label": "not_supported" }, { "subclaim": "The patient experienced two cardiac arrests.", "support_label": "supported" }, { "subclaim": "One cardiac arrest occurred before the operation.", "support_label": "not_supported" }, { "subclaim": "One cardiac arrest occurred during the operation.", "support_label": "not_supported" }, { "subclaim": "The total duration of cardiac arrest was 30 minutes.", "support_label": "not_supported" }, { "subclaim": "V-V ECMO was initiated because of severe hypoxia.", "support_label": "supported" }, { "subclaim": "V-V ECMO was initiated because of hypercapnia.", "support_label": "supported" }, { "subclaim": "ECMO was performed for 6 days.", "support_label": "not_supported" }, { "subclaim": "Mechanical ventilation lasted 11 days.", "support_label": "supported" }, { "subclaim": "The patient was discharged on the 31st day after surgery.", "support_label": "supported" }, { "subclaim": "The patient had recovered completely.", "support_label": "supported" }, { "subclaim": "The patient had no neurological deficit at discharge.", "support_label": "supported" } ] }, { "id": "multiclinsum_test_162_en.txt", "fulltext": "A 78-year-old woman with an unremarkable past medical history presented to the clinic with symptoms of progressively worsening myelopathy including gait dysfunction and impairment of upper extremity fine motor skills. Noncontrast MRI of the cervical spine demonstrated multilevel degenerative disease and a dorsal intradural extramedullary lesion extending from C3-C6.\nThe patient underwent an elective posterior C3-7 decompression, C3-T1 instrumented fusion, and resection of intradural tumor. Final pathology was psammomatous meningioma. The patient tolerated the procedure well and postoperatively was transferred to the neurological ICU for close monitoring.\nThe patient was initially discharged from the hospital to an inpatient rehabilitation facility on POD 6. At the time of discharge, she was awake, oriented, and followed commands in all extremities with some mild weakness in the right deltoid and biceps, graded 4/5; the remaining muscle groups were 5/5. On POD 10, the patient developed progressive lethargy and was readmitted to the hospital for further evaluation. Upon readmission, she opened her eyes to verbal command, had incomprehensible speech, and would move all extremities spontaneously with strength 3/5 but did not follow commands. She was afebrile with WBC = 6.9 and no metabolic abnormalities. Given her recent intradural surgery, a lumbar puncture was performed. CSF cytology demonstrated 397 WBC, 20 RBC, 291 protein, and 40 glucose. CSF PCR was positive for HSV 1. Interestingly, intracranial imaging did not demonstrate the typical findings associated with herpes encephalitis . She was initially placed on broad spectrum antibiotics in addition to antiviral therapy. She was also connected to continuous EEG monitoring, found to be in status epilepticus, and required escalating therapy to the point of intubation with midazolam infusion. Seizure control was ultimately achieved, and she was maintained on levetiracetam 1500 mg q12H for 30 days and lacosamide 200 mg q12H for 7 days. The remainder of her infectious work-up was unremarkable, allowing her to be narrowed to only a 21-day course of IV acyclovir 500 mg q12H. Due to acute respiratory failure from encephalopathy, she underwent tracheostomy and PEG placement (POD 29); she underwent repeat MRI approximately 2 weeks after HSV diagnosis which still lacked typical findings of HSV . However, she continued to improve clinically; at the time of discharge, she would open her eyes spontaneously and followed simple commands in all extremities. Approximately 3 months out from being diagnosed with HSV encephalitis, she was oriented twice and followed commands in all 4 extremities with 5/5 strength in the bilateral upper and 3/5 in the bilateral lower extremities.\nAt a three-month follow-up, the patient presented no new symptoms. The PEG was still in place and EEG revealed excessive theta waves during wakefulness and bilateral midtemporal delta slowing (left more prevalent than right). Though the patient had dysarthria and poor attention/processing, she followed commands in all 4 extremities consistent with her last evaluation. Vimpat 200 BID and 1500 mg of Keppra were prescribed for ongoing clonus spasticity. All other medications were continued as prescribed. In the following month, the patient had a normal LOC, very slight dysarthria, and improved situational awareness. No recent seizures had occurred. Lacosamide was reduced to 150 mg every 12 hours and Vimpat was reduced to 150 BID. Upon final examination, she followed commands in all 4 extremities with 5/5 strength in the bilateral upper and 4-/5 in the bilateral lower extremities.", "summary": "We report a case of a 78-year-old woman with no known prior history of HSVE and declining mental status eleven days after a posterior C3-T1 decompression and instrumented fusion following resection of an intradural extramedullary tumor, confirmed to be meningioma on final pathology. Reactivation of HSV-1 encephalitis was suspected to be the underlying cause of her symptoms, though MRI scans of the brain for HSVE were negative. The patient reacted positively to a 21-day treatment of acyclovir and was discharged with a neurological status comparable to her preoperative baseline. This case contributes to the literature in that it is the first reported instance of HSVE reactivation after intradural cervical spinal surgery with negative MRI findings.", "subclaim_evaluations": [ { "subclaim": "The patient was a 78-year-old woman.", "support_label": "supported" }, { "subclaim": "She had no known prior history of HSV encephalitis.", "support_label": "supported" }, { "subclaim": "She had declining mental status eleven days after surgery.", "support_label": "supported" }, { "subclaim": "The surgery was a posterior C3-T1 decompression and instrumented fusion.", "support_label": "supported" }, { "subclaim": "The surgery followed resection of an intradural extramedullary tumor.", "support_label": "supported" }, { "subclaim": "The tumor was confirmed to be meningioma on final pathology.", "support_label": "supported" }, { "subclaim": "Reactivation of HSV-1 encephalitis was suspected as the underlying cause of her symptoms.", "support_label": "supported" }, { "subclaim": "MRI scans of the brain for HSV encephalitis were negative.", "support_label": "supported" }, { "subclaim": "The patient received a 21-day treatment of acyclovir.", "support_label": "supported" }, { "subclaim": "The patient was discharged with a neurological status comparable to her preoperative baseline.", "support_label": "not_supported" }, { "subclaim": "This case is the first reported instance of HSV encephalitis reactivation after intradural cervical spinal surgery.", "support_label": "not_supported" }, { "subclaim": "The case had negative MRI findings.", "support_label": "not_supported" } ] }, { "id": "multiclinsum_test_96_en.txt", "fulltext": "A 64-year-old male initially presented with painless hematuria in September 2017 and was treated by a partial cystectomy as stage I BC. The patient showed local recurrence in August 2018 and underwent transurethral resection of bladder tumor (TURBT) followed by regular intravesical chemotherapy with epirubicin after TURBT. In March 2020, the patient approached to our hospital complaining about severe anorexia and fatigue. Subsequent FDG-PET/CT scan showed bladder recurrence with local invasion of the adjacent right lower ureter, resulting in the upper urinary tract dilation. Multiple lymph node metastasis, liver metastasis and lumbar metastasis (L5) were also identified . Ureteral stent placement was performed due to obstructive renal insufficiency and hepatic biopsy confirmed metastatic high-grade urothelial carcinoma with positive PD-L1 expression on 1% of the tumor cells. Then, next-generation sequencing (NGS) by a commercial laboratory (Genecast Biotechnology Co., Ltd, Jiangsu, China) identified ERBB2 p.V842I in both circulating tumor DNA (ctDNA) and biopsy sample with an allele frequency of 3.94% and 26.07%, respectively .\nThe patient received one cycle of palliative reduced-dose albumin-bound paclitaxel due to elevated serum creatinine level (Scr 204μmol/L). The tumor biomarker CA199 was even higher after first cycle chemotherapy without any relief of his symptoms. Based on his NGS result, pyrotinib (400mg orally daily) was started from April 10, 2020. Within one month, his tumor markers dramatically improved with remission of clinical symptoms . Due to renal dysfunction, the patient performed FDG-PET/CT scan for treatment efficacy assessment, which showed significantly decreased FDG uptake of multiple metastatic sites in May 2020 . Even though the overall response was considered stable based on the RECIST 1.1 criteria, the decrease in FDG uptake and remission of clinical symptoms indicated the patient responded well to the HER2 targeting therapy. However, he developed G3 diarrhea and terminated the medication on May 20, 2020 (The pyrotinib treatment lasted for 40 days). The third-line treatment with the PD-1 inhibitor tislelizumab (200mg every three weeks) was next started but the disease progressed after 2 months . ctDNA was collected in August 2020 and ERBB2 p.V842I with an allele frequency of 2.06% was identified by NGS. Ureteral stent removal was performed with improved renal function. Four cycles of PD-L1 inhibitor durvalumab, oxaliplatin and gemcitabine were administered, but level of CA199 gradually increased. NGS was performed again showing the same ERBB2 mutation with an allele frequency of 1.58%. Reduced dose of pyrotinib (240mg orally daily) was added, the patient’s tumor again responded with significant improvement of CA199 within 20 days. Dynamic monitoring of the ctDNA again confirmed ERBB2 p.V842I by NGS with a lower allele frequency of 0.41% . The regimen was generally tolerated this time but the tumor marker gradually increased in this patient. PET/CT evaluation revealed disease progression in March 2021, and the treatment was then discontinued . The length of time for reduced pyrotinib therapy was 4.5 months. The patient passed away on July 1st, 2021, and the post-recurrence survival was 16 months.", "summary": "We described a patient with metastatic bladder urothelial carcinoma (BUC) carrying a HER2 V842I mutation both in circulating tumor DNA (ctDNA) and biopsy sample. The patient was then treated with a HER2 tyrosine kinase inhibitor, pyrotinib, and responded well. However, the targeting treatment was terminated due to G3 diarrhea. Reduced dose of pyrotinib was later added to late-line treatment, the patient's tumor again responded with a significant decrease in CA199.", "subclaim_evaluations": [ { "subclaim": "The patient had metastatic bladder urothelial carcinoma.", "support_label": "supported" }, { "subclaim": "The patient had a HER2 V842I mutation.", "support_label": "supported" }, { "subclaim": "The HER2 V842I mutation was detected in circulating tumor DNA.", "support_label": "supported" }, { "subclaim": "The HER2 V842I mutation was detected in a biopsy sample.", "support_label": "supported" }, { "subclaim": "The patient was treated with pyrotinib.", "support_label": "supported" }, { "subclaim": "The patient responded well to pyrotinib.", "support_label": "supported" }, { "subclaim": "The treatment was terminated due to grade 3 diarrhea.", "support_label": "supported" }, { "subclaim": "A reduced dose of pyrotinib was added to late-line treatment.", "support_label": "supported" }, { "subclaim": "The patient's tumor responded to the reduced dose of pyrotinib.", "support_label": "supported" }, { "subclaim": "There was a significant decrease in CA199.", "support_label": "supported" } ] }, { "id": "multiclinsum_test_3143_en.txt", "fulltext": "We report the case of an 11-year-old girl who had been presenting a severe asthenia for a month, orthostatic dizziness, headaches and abdominal pain. Patient familial history was remarkable due to the total absence of the pericardium associated with hypo-gammaglobulinemia and bronchiectasis in her 9-year-old sister [5]. Patient personal history was uneventful.\n\nA previous recent laboratory examination had revealed moderate inflammation (leucocyte count: 13,440/mm; CRP: 30 mg/L) but increased sedimentation rate (68 mm/h), and slightly increased fasting glycemia (106 mg/dL) with a normal insulin concentration. Urine analysis showed bacteriuria. On that basis, she received a treatment with sulfamethoxazol.\n\nPatient status did not improve, and thus, she was referred to our institution for endocrinological and cardiological advice. A physical examination confirmed recent weight loss (2.5 kg in 10 days), systemic arterial hypertension (147/104 mm Hg) in an upright position dropping in a supine position (80/60 mm Hg), a normal heart rate and normal transcutaneous oxygen saturation.\n\nThe patient was pale with wet and cold extremities. Precordium was hyperactive, and cardiac and pulmonary auscultation was normal as was abdominal palpation.\n\nAn electrocardiogram showed left ventricular hypertrophy according to Davignon’s criteria with non-specific repolarization anomalies and a prolonged QT interval corrected by the Bazzett’s formula (QTc: 470 ms).\n\nEchocardiography demonstrated global left ventricular hypertrophy with a dilated aortic root (Z-score calculated according to: 2.5) and grade I aortic insufficiency.\n\nAbdominal ultrasound showed the presence of a right-sided adrenal mass.\n\nThe left-sided adrenal gland and all other intra-abdominal organs were normal.\n\nAn oral glucose tolerance test showed moderate hyperglycemia associated with hyperinsulinemia. Cortisol- and thyroid hormone serum levels were normal. Noradrenaline and normetanephrine urine concentrations were strongly increased (>711 μg/24H and >9000 μg/24H, respectively). The right-sided adrenal mass was confirmed via magnetic resonance imaging, and iodine-123-metaiodobenzylguathdine ([123I]-mIBG) scintigraphy confirmed isolated tracer fixation on the right adrenal gland.\n\nThe patient was scheduled for surgery and stabilized until then using a combination of a β-blocker and calcium channel antagonist, allowing for blood pressure control. She underwent total adrenalectomy via laparoscopy. Anatomo-pathology confirmed the diagnosis of a typical pheochromocytoma without any signs of malignancy.\n\nMicroscopic analysis showed a nest-shaped tumor architecture with large polygonal cells. The central part of the tumor presented some ischemic necrotic areas and vascular structures with recent thrombosis but no signs of vascular invasion. There was no mitotic activity.\n\nImmune-histological examination proved a high degree of positivity for the neural cell adhesion molecule CD56 and for the markers of neuroendocrine tumors chromogranine and synatophysine. The level of cell proliferation was estimated to be lower than 1%.\n\nA genetic evaluation was carried out. DNA sequence analysis allowed for the exclusion of pathogenic gene mutations implicated in hereditary paragangliomas and pheochromocytoma (SDHA, SDHB, SDHC, SDHD, SDHAF2, TMEM 127, MAX, VHL, FH, MDH2 and exons 10, 11, 13, 14 and 16 of the RET gene) but demonstrated a somatic mutation c.57C>T in exon 3 of the tumor suppressor gene von Hippel-Lindau.\n\nCardiac examination, including echocardiography performed 2 weeks after right-sided adrenalectomy, showed residual left ventricular hypertrophy but normalization of the aortic root dimension (Z-score: 0.7) and QTc duration.\n\nTwo years after the operation, the patient complained about dizziness, palpitations and chest pain. The clinical examination, including blood pressure, was normal. Concentrations of blood and urine catecholamines were in the normal range. Abdominal MRI showed a normal left-sided adrenal gland an empty right-sided adrenal lodge. Endocrinological and cardiological examinations, including echocardiography and abdominal MRI, were repeated and remain normal after a follow-up period of 5 years.", "summary": "We report the case of an 11-year-old girl who complained about severe asthenia, orthostatic dizziness and abdominal pain for 4 weeks. The primary investigation concluded on febrile urinary tract infection treated by antibiotics. Symptom persistence prompted cardiological and endocrinological investigations. A fluctuation in blood pressure, long QT interval, dilation of the aortic root and left ventricular hypertrophy were documented. Elevated levels of urinary catecholamines together with the presence of a right-sided adrenal mass shown via abdominal ultrasound and magnetic resonance imaging were highly suggestive of a pheochromocytoma. This was confirmed by through iodine-123-metaiodobenzylguathdine ([123I]-mIBG) scintigraphy. Genetic analysis allowed for the exclusion of pathogenic mutations in genes implicated in hereditary paragangliomas and pheochromocytomas but showed a rare somatic mutation in exon 3 of the von Hippel-Lindau gene. The patient was treated with a β-blocker and calcium channel antagonist and underwent laparoscopic right-sided adrenalectomy. Cardiac manifestations resolved soon after surgery indicating that they were secondary to the pheochromocytoma. After 5 years of follow-up, the patient remains asymptomatic without any sign of tumor recurrence.", "subclaim_evaluations": [ { "subclaim": "The patient was an 11-year-old girl.", "support_label": "supported" }, { "subclaim": "She had symptoms of severe asthenia, orthostatic dizziness, and abdominal pain for 4 weeks.", "support_label": "supported" }, { "subclaim": "The primary investigation concluded on febrile urinary tract infection.", "support_label": "not_supported" }, { "subclaim": "The febrile urinary tract infection was treated by antibiotics.", "support_label": "not_supported" }, { "subclaim": "Symptoms persisted after treatment.", "support_label": "not_supported" }, { "subclaim": "Cardiological and endocrinological investigations were performed.", "support_label": "supported" }, { "subclaim": "A fluctuation in blood pressure was documented.", "support_label": "supported" }, { "subclaim": "A long QT interval was documented.", "support_label": "supported" }, { "subclaim": "Dilation of the aortic root was documented.", "support_label": "supported" }, { "subclaim": "Left ventricular hypertrophy was documented.", "support_label": "supported" }, { "subclaim": "Elevated levels of urinary catecholamines were found.", "support_label": "supported" }, { "subclaim": "A right-sided adrenal mass was shown via abdominal ultrasound.", "support_label": "supported" }, { "subclaim": "A right-sided adrenal mass was shown via magnetic resonance imaging.", "support_label": "supported" }, { "subclaim": "The findings were highly suggestive of pheochromocytoma.", "support_label": "supported" }, { "subclaim": "Pheochromocytoma was confirmed by iodine-123-metaiodobenzylguanidine ([123I]-mIBG) scintigraphy.", "support_label": "supported" }, { "subclaim": "Genetic analysis excluded pathogenic mutations in genes implicated in hereditary paragangliomas and pheochromocytomas.", "support_label": "supported" }, { "subclaim": "A rare somatic mutation in exon 3 of the von Hippel-Lindau gene was found.", "support_label": "supported" }, { "subclaim": "The patient was treated with a β-blocker.", "support_label": "supported" }, { "subclaim": "The patient was treated with a calcium channel antagonist.", "support_label": "supported" }, { "subclaim": "The patient underwent laparoscopic right-sided adrenalectomy.", "support_label": "supported" }, { "subclaim": "Cardiac manifestations resolved soon after surgery.", "support_label": "supported" }, { "subclaim": "The cardiac manifestations were considered secondary to the pheochromocytoma.", "support_label": "supported" }, { "subclaim": "After 5 years of follow-up, the patient remained asymptomatic.", "support_label": "supported" }, { "subclaim": "There was no sign of tumor recurrence after 5 years of follow-up.", "support_label": "supported" } ] }, { "id": "multiclinsum_test_3041_en.txt", "fulltext": "A 68-year-old man presented to the emergency department with progressive dyspnea and lower-limb edema leading to anasarca associated with neuropathic pain. The patient had no significant past medical history but reported undergoing outpatient evaluation in which a transthoracic echocardiogram (TTE) revealed reduced left ventricular ejection fraction (LVEF) and a pattern of left ventricular hypertrophy. His vital signs were within the normal limits but jugular engorgement, ascites, and lower limb edema up to the point of anasarca were observed. Physical examination notably revealed a rupture of the right biceps brachii tendon. Laboratory tests showed a hemoglobin level of 13.8 g/dL, creatinine 1.42 mg/ dL, blood urea nitrogen of 18 mg/dL, and N-terminal pro B-type natriuretic peptide (NT-proBNP) of 7461 pg/mL.\n\nChest X-ray reported cardiomegaly with aortic elongation. An electrocardiogram revealed sinus rhythm, right-axis deviation, low QRS voltage, first-degree atrioventricular block, pseudo-infarct pattern in precordial leads V1–V3, poor R progression, and alterations in high lateral repolarization.\n\nThe TTE indicated a non-dilated left ventricle with concentric hypertrophy as well as severely thickened walls with a speckled appearance, LVEF of 30%, and severely reduced longitudinal strain (−6.2%), demonstrating higher strain in apical segments than basal segments in a relative apical sparing. The left ventricular posterior wall measured 21.3 mm, interatrial septum thickness was 5.35 mm, and there was severe dilation of the left atrium, dilated right ventricle with decreased global contractility, moderate mitral regurgitation, and a small pericardial effusion. A coronary angiogram was done to rule out ischemic cardiomyopathy.\n\nCardiac magnetic resonance imaging (CMRI) revealed severe symmetric hypertrophy, significant dilation of the left atrium, marked thickening with involvement of papillary muscles, diffuse thickening of both ventricles, severe biventricular systolic dysfunction with an LVEF of 32% and right ventricular ejection fraction of 26%. A native T1 value of 1225 ms (normal value is less than 1000 ms) was obtained at the septum on mid-cavity short-axis map. Post-gadolinium enhancement displayed marked hypointensity of the blood pool, patchy up-take involving the entire myocardium, subendocardium, and epicardium, and the zebra sign. T1 mapping post-gadolinium revealed a severely increased extracellular volume of 72% (normal less than 30%), consistent with cardiac amyloidosis. Pyrophosphate scintigraphy indicated Perugini grade 3.\n\nHematologic tests were conducted to rule out light-chain amyloidosis, which is revealed by free Lambda light chains of 32.6 mg/L and Kappa light chains of 95.7 mg/L (with a ratio of 2.9). Serum and urine immunofixation found that these light chains were undetectable, protein electrophoresis showed no monoclonal peaks, and bone marrow flow cytometry indicated no plasma cell neoplasia. A subcutaneous adipose tissue biopsy was negative by Congo red staining for amyloid. A myocardial biopsy revealed myocytes with broad cytoplasm surrounded by clear pinkish amorphous material, which was focal positive for Congo red staining, showing as apple green in color. A genetic study was conducted, reporting a variant c.424G>A (p.Val142Ile) in heterozygosity in the exon of the TTR gene, confirming the presence of TTRv amyloidosis.", "summary": "A 68-year-old man presented with heart failure symptoms, biceps tendon rupture, neuropathic pain in the extremities, and an electrocardiogram showing low QRS voltage and a pseudo-infarct pattern. Transthoracic echo-cardiogram revealed a left ventricular ejection fraction of 30%, severely thickened walls with a speckled appearance, a global longitudinal strain of −6.2% in a bull’s eye pattern, and a left ventricular posterior wall thickness of 21.3 mm. Cardiac magnetic resonance imaging showed severe symmetric hypertrophy, moderate global dys-function, and an elevated native T1 value of 1225 milliseconds. Post-gadolinium T1 mapping revealed a significantly increased extracellular volume of 72%. Perugini grade 3 pyrophosphate scintigraphy, negative hemato-logical tests, and endomyocardial biopsy confirmed the diagnosis of amyloidosis, without monoclonal spikes. Genetic testing identified a heterozygous c.424G>A (p.Val142Ile) variant in the transthyretin gene, consistent with variant transthyretin amyloidosis.", "subclaim_evaluations": [ { "subclaim": "The patient is a 68-year-old man.", "support_label": "supported" }, { "subclaim": "The patient had heart failure symptoms.", "support_label": "supported" }, { "subclaim": "The patient had a biceps tendon rupture.", "support_label": "supported" }, { "subclaim": "The patient had neuropathic pain in the extremities.", "support_label": "supported" }, { "subclaim": "The electrocardiogram showed low QRS voltage.", "support_label": "supported" }, { "subclaim": "The electrocardiogram showed a pseudo-infarct pattern.", "support_label": "supported" }, { "subclaim": "Transthoracic echocardiogram revealed a left ventricular ejection fraction of 30%.", "support_label": "supported" }, { "subclaim": "Transthoracic echocardiogram showed severely thickened walls with a speckled appearance.", "support_label": "supported" }, { "subclaim": "Transthoracic echocardiogram showed a global longitudinal strain of −6.2% in a bull’s eye pattern.", "support_label": "supported" }, { "subclaim": "Transthoracic echocardiogram showed a left ventricular posterior wall thickness of 21.3 mm.", "support_label": "supported" }, { "subclaim": "Cardiac magnetic resonance imaging showed severe symmetric hypertrophy.", "support_label": "supported" }, { "subclaim": "Cardiac magnetic resonance imaging showed moderate global dysfunction.", "support_label": "not_supported" }, { "subclaim": "Cardiac magnetic resonance imaging showed an elevated native T1 value of 1225 milliseconds.", "support_label": "supported" }, { "subclaim": "Post-gadolinium T1 mapping revealed a significantly increased extracellular volume of 72%.", "support_label": "supported" }, { "subclaim": "Perugini grade 3 pyrophosphate scintigraphy was performed.", "support_label": "supported" }, { "subclaim": "Endomyocardial biopsy confirmed the diagnosis of amyloidosis.", "support_label": "supported" }, { "subclaim": "Genetic testing identified a heterozygous c.424G>A (p.Val142Ile) variant in the transthyretin gene.", "support_label": "supported" }, { "subclaim": "The variant is consistent with variant transthyretin amyloidosis.", "support_label": "supported" } ] }, { "id": "multiclinsum_test_1773_en.txt", "fulltext": "A 74-year-old woman who was treated outside our hospital due to complaints of general weakness, hematuria, dysuria, and decreased renal function was transferred to Chosun University Hospital, Gwangju, Korea, as her renal function did not improve despite treatment.\nClinically, rapid progressive glomerulonephritis (RPGN) was suspected. Two days after admission, US-guided percutaneous renal biopsy was performed to confirm the pathologic diagnosis, before initiating steroid treatment. Contrary to expectations, the light microscopic examination identified diffuse infiltration of pleomorphic cells throughout the specimen. The pleomorphic cells were immunoreactive for CD20, bcl-2, bcl-6, and MUM-1, but negative for CD3, CD10, and Epstein-Barr encoding region in situ hybridization . No fluorescence deposit was identified during immunofluorescence examination. In electro-microscopic examination, no electron-dense deposit was observed, and the glomerular basement membrane appeared normal in thickness, contour, and texture. However, strikingly, diffuse prominent infiltration of atypical lymphocytes was observed in the interstitium. The cells displayed round to oval cleaved and non-cleaved nuclei with variable clumping of chromatin, and large prominent, marginated nucleoli . We diagnosed the condition as DLBCL, not medical renal disease. After pathologic diagnosis, radiologic re-evaluation was performed. Abdominal CT examination (with contrast) revealed diffuse homogeneous enhancement in both kidneys without definite visible cortico-medullary differentiation, and lymphomatous involvement was diagnosed. A few mild enlargements of lymph nodes in the pericardial and periaortic chains were identified, and such nodes were considered to indicate secondary lymphomatous involvement. On fluorodeoxyglucose-positron emission tomography CT, intense hypermetabolism (19.6) was identified in both kidneys, and some lymph nodes exhibited mild hypermetabolism . In the laboratory tests, serum lactate dehydrogenase (LDH) level was elevated to 376 U/L (125-220 U/L). The international prognostic index (IPI) was reported as 3 when the following laboratory data and clinicopathologic factors were considered [old age, 1; Eastern Cooperative Oncology Group (ECOG) performance status (PS), 1; Ann Arbor stages III–IV, 0; serum level > 1 × normal, 1; and > 1 extranodal site, 0].\nThe patient had no previous renal problems.\nThere was no specific personal or family history.\nThe patient looked ill.\nAfter admission, the blood urea nitrogen (normal range, 7.0-20.1 mg/dL)/creatinine (0.57-1.11 mg/dL) levels on June 30, July 9, and July 11, 2022 were as follows: 27.7/4.09; 41.0/6.61; and 48/7.62 mg/dL, respectively.\nRadiologically, renal US exhibited heterogeneously increased parenchymal echogenicity and a 1.43 cm-sized hypoechoic cystic lesion in the right kidney. Thus, the radiologist suggested probable medical renal disease with a right cystic lesion. During abdominal CT (contrast-free CT while admitted to the emergency room), no neoplastic lesion was suspected.", "summary": "Herein, we report a 74-year-old woman with primary diffuse large B-cell lymphoma who presented with AKI diagnosed by ultrasound-guided needle biopsy. We also report the clinicopathologic findings of 121 PRL cases reported since 1989, by conducting a literature review of published cases.", "subclaim_evaluations": [ { "subclaim": "The patient is a 74-year-old woman.", "support_label": "supported" }, { "subclaim": "The patient had primary diffuse large B-cell lymphoma.", "support_label": "supported" }, { "subclaim": "The patient presented with acute kidney injury.", "support_label": "supported" }, { "subclaim": "Acute kidney injury was diagnosed by ultrasound-guided needle biopsy.", "support_label": "supported" }, { "subclaim": "A literature review of 121 PRL cases was conducted.", "support_label": "not_supported" }, { "subclaim": "The literature review included cases reported since 1989.", "support_label": "not_supported" } ] }, { "id": "multiclinsum_test_981_en.txt", "fulltext": "A 47-year-old man was initially diagnosed as dysphagia. On the next day, he developed dysarthria and tongue deviation to the left, and he visited our hospital. He had no history of trauma nor any other significant medical history. Blood pressure was 184/126 mmHg. Neurological examinations revealed leftward deviation of the tongue on protrusion and dysarthria, suggesting a left hypoglossal nerve palsy. There were no other neurological deficits. Diffusion-weighted magnetic resonance images (MRI) did not demonstrate any lesions that could cause left hypoglossal nerve palsy . Axial T2-CUBE MRI demonstrated a false lumen of ICAD that compressed the outlet portion of the hypoglossal nerve tube and dilation of the perineural space in the hypoglossal canal . The false lumen of ICAD was adjacent to the hypoglossal canal at its distal side and protruded toward the hypoglossal neural tube. These findings indicated that direct compression by the false lumen was the cause of hypoglossal nerve palsy . MR angiography (MRA) showed dissection of the left ICA accompanied with a false lumen . The patient was admitted and we started transoral administration of amlodipine (5 mg/day) and azilsartan (20 mg/day) for antihypertensive treatment. On the 2nd day, he felt headache, and transoral administration of loxoprofen was started. On the 7th day, he was started on aspirin (100 mg/day) and clopidogrel (75 mg/day) for prevention of thromboembolism from the dissected portion. Cerebral angiography performed on the 8th day showed an ICAD consistent with the findings on MRI and MRA . Cone-beam computed tomography (CBCT) showed protrusion of the false lumen to the hypoglossal canal .\nAlthough medical treatment was continued, his headache worsened, and the neurological symptoms were not improved. Therefore, CAS was performed on the 19th day to thrombose the false lumen and decompress the hypoglossal nerve. A 6Fr guiding catheter (Axcelguide MSK, Medikit, Tokyo, Japan) was inserted through the right brachial artery and a 4-6Fr catheter (Dymon catheter, Silux, Saitama, Japan) was placed in the left common carotid artery. An embolic protection device (FilterWire EZ, Boston Scientific, MA) was advanced through the lesion and a filter was deployed in the ICA at the petrous portion. A carotid stent (Wallstent, Boston Scientific) was advanced to the dissected portion and deployed. Angiography immediately after stenting showed dilatation of the true lumen and congestion of contrast medium in the false lumen . There were no neurological symptoms or vital changes throughout the procedures. Pre- or post-dilation was not performed because the vessel was sufficiently dilated and there was a risk of enlargement or rupture of the false lumen.\nHis headache gradually improved after CAS and disappeared on the 25th day. His postoperative course was uneventful and he was discharged on the 26th day. No improvement of hypoglossal nerve palsy was observed at the time of discharge. At 1 month after discharge, neurological symptoms, such as tongue deviation and dysarthria, improved. Cerebral angiography performed at month 6 showed well-dilated ICA and disappearance of false lumen .", "summary": "A 47-year-old man presented with headache, dysphagia, dysarthria, and tongue deviation to the left. He had no history of trauma nor any other significant medical history. Axial T2-CUBE MRI and MRA showed dissection of the left ICA accompanied with a false lumen. These findings indicated that direct compression by the false lumen was the cause of hypoglossal nerve palsy. Although medical treatment was continued, symptoms were not improved. Therefore, CAS was performed to thrombose the false lumen and decompress the hypoglossal nerve. His symptoms gradually improved after CAS and angiography performed at month 6 showed well-dilated ICA and disappearance of false lumen.", "subclaim_evaluations": [ { "subclaim": "The patient is a 47-year-old man.", "support_label": "supported" }, { "subclaim": "He presented with headache.", "support_label": "supported" }, { "subclaim": "He presented with dysphagia.", "support_label": "supported" }, { "subclaim": "He presented with dysarthria.", "support_label": "supported" }, { "subclaim": "He presented with tongue deviation to the left.", "support_label": "supported" }, { "subclaim": "He had no history of trauma.", "support_label": "supported" }, { "subclaim": "Axial T2-CUBE MRI showed dissection of the left ICA.", "support_label": "supported" }, { "subclaim": "MRA showed a false lumen.", "support_label": "supported" }, { "subclaim": "The findings indicated direct compression by the false lumen was the cause of hypoglossal nerve palsy.", "support_label": "supported" }, { "subclaim": "Medical treatment was continued.", "support_label": "supported" }, { "subclaim": "Symptoms were not improved.", "support_label": "supported" }, { "subclaim": "CAS was performed.", "support_label": "supported" }, { "subclaim": "CAS was performed to thrombose the false lumen.", "support_label": "supported" }, { "subclaim": "CAS was performed to decompress the hypoglossal nerve.", "support_label": "supported" }, { "subclaim": "His symptoms gradually improved after CAS.", "support_label": "supported" }, { "subclaim": "Angiography performed at month 6 showed well-dilated ICA.", "support_label": "supported" }, { "subclaim": "Angiography performed at month 6 showed disappearance of false lumen.", "support_label": "supported" } ] }, { "id": "multiclinsum_test_1626_en.txt", "fulltext": "The case in question concerns a 64-year-old Caucasian postmenopausal woman presenting with pain, abdominal distension, and an altered intestinal transit.\nThoracic and abdominopelvic computed tomography (CT) scans revealed massive peritoneal carcinomatosis, extensive ascites, involvement of the major omentum, extensive involvement small intestine mesentery, diffuse involvement of the parietal peritoneum, implants at the bottom of the Douglas pouch, and probable implants on the ovarian surface, although of normal size . Her plasma CA-125 tumour marker levels were 1,110.9 U/mL, and those of the remaining tumour markers fell within a normal range. An omentum biopsy was compatible with high-grade serous carcinoma, with positive expression for WT-1, p53, CK-7 and negative expression for CK20 and TTF-1, with tube-ovarian-peritoneal origin.\nGiven the confirmed diagnosis of a primary peritoneal carcinoma of gynaecological origin stage IIIC and after assessment by a multidisciplinary committee that considers unresectable disease due to mesenteric involvement, neoadjuvant chemotherapy with intravenous (i.v.) paclitaxel 175 mg/m2 and i.v. carboplatin AUC 6 at three-week intervals was prescribed. The patient received three cycles of this treatment, showing a significant partial response on the follow-up CT scans, and plasma CA-125 tumour marker levels of 65 U/mL (levels at diagnosis: 1110.9 U/mL).\nSurgery was subsequently performed, achieving optimal cytoreduction, and the patient had a catheter placed for the administration of the intraperitoneal chemotherapy. The pathological study of all samples obtained during the procedure revealed a high-grade serous carcinoma.\nFollowing the intervention, a total of four cycles of adjuvant intraperitoneal (i.p.) chemotherapy consisting of i.v. paclitaxel 175 mg/m2 (day 1), i.p. cisplatin 75 mg/m2 (day 2), and i.p. paclitaxel 60 mg/m2 (day 8) were administered. The patient achieved a complete response, although she developed grade-2 asthenia and grade-3 neutropenia due to treatment-related toxicity that mandated a delay in the dosing and support with granulocyte-colony stimulating factors (G-CSFs).\nSeven months after receiving the last cycle of platinum-based chemotherapy, her CA-125 tumour marker levels were 104 U/mL, and mediastinal lymph node and peritoneal recurrence were identified in the follow-up CT scans. At this time, a germline mutation study was carried out in BRCA, being negative. Given that these findings were considered to be indicative of progression after a PFI of seven months, second-line chemotherapy was started with i.v. trabectedin 1.1 mg/m2 (day 1) in combination with i.v. PLD 30 mg/m2 (day 1) at 21-day cycles. The patient achieved a partial response after the third cycle (CA-125: 11.8 U/mL) .\nChemotherapy with trabectedin and PLD was continued; however, given that the patient experienced haematological toxicity (grade-4 neutropenia), the dose of PLD had to be reduced to 25 mg/m2 and that of trabectedin to 0.9 mg/m2 during the sixth cycle. PLD was subsequently discontinued altogether due to the onset of toxicity associated with this drug (grade-2 mucositis and grade-3 asthenia). From then on, she received i.v. trabectedin 0.9 mg/m2 in monotherapy at 21-day cycles, with good tolerance and referring only grade-1 asthenia that resolved within two to three days and did not limit her during her basic activities of daily living.\nAfter ten cycles of treatment, and specifically four cycles of trabectedin in monotherapy, the dose of trabectedin had to be reduced to 0.75 mg/m2 every 21 days due to the onset of grade-3 neutropenia and grade-2 thrombopenia, which mandated frequent delays in the dosing and even G-CSF support. Nevertheless, the subsequent follow-up CT scans performed periodically continued to show evidence of complete response. The patient received a total of 35 cycles of trabectedin (six in combination with PLD and then 29 in monotherapy). During this time, she maintained an excellent quality of life, experiencing no late or cumulative toxicity, and being able to perform her usual activities.\nBecause peritoneal progression was subsequently detected after a PFI of three years, a third line of treatment with i.v. carboplatin (area under the curve [AUC] = 4) (day 1), i.v. gemcitabine 1,000 mg/m2 (days 1 and 8 of every 21-day cycle), and i.v bevacizumab 15 mg/kg (day 1) was started. A subsequent follow-up CT scan carried out after the third cycle of this therapy showed signs of partial response. Given that the response persisted after six treatment cycles, chemotherapy was suspended and treatment with bevacizumab in monotherapy was started. The patient has received a total of 12 cycles of maintenance treatment with bevacizumab in monotherapy to date, having tolerated the treatment well and maintained a partial response.", "summary": "A 64-years-old postmenopausal woman with pain, abdominal distension, and an altered intestinal transit and with partially platinum-sensitive recurrent ovarian cancer, was successfully treated with a second line of trabectedin chemotherapy in combination with PLD, followed by trabectedin in monotherapy. This case proves the effectiveness of the combination of trabectedin and PLD and demonstrates how the administration of trabectedin, even in monotherapy, allows to maintain an adequate clinical response with good tolerance to the treatment during more than two years of drug administration.", "subclaim_evaluations": [ { "subclaim": "The patient is a 64-year-old postmenopausal woman.", "support_label": "supported" }, { "subclaim": "The patient had pain.", "support_label": "supported" }, { "subclaim": "The patient had abdominal distension.", "support_label": "supported" }, { "subclaim": "The patient had an altered intestinal transit.", "support_label": "supported" }, { "subclaim": "The patient had partially platinum-sensitive recurrent ovarian cancer.", "support_label": "supported" }, { "subclaim": "The patient was treated with a second line of trabectedin chemotherapy in combination with PLD.", "support_label": "supported" }, { "subclaim": "The patient was later treated with trabectedin in monotherapy.", "support_label": "supported" }, { "subclaim": "The combination of trabectedin and PLD was effective.", "support_label": "supported" }, { "subclaim": "Trabectedin in monotherapy allowed an adequate clinical response.", "support_label": "supported" }, { "subclaim": "The treatment was well tolerated.", "support_label": "supported" }, { "subclaim": "The treatment duration was more than two years.", "support_label": "supported" } ] }, { "id": "multiclinsum_test_471_en.txt", "fulltext": "A 72-year-old woman (40.3 kg, 139 cm) was referred to our pain clinic for the treatment of low back pain after two back surgeries. She had first undergone back surgery [posterior lumbar interbody fusion (PLIF at L4–5) plus spinal stabilization (L3)] for lumbar spinal canal stenosis 4 years prior to the current presentation. Two weeks after the initial surgery, she underwent reoperation because of screw placement errors, and her symptoms disappeared after surgery. However, her low back pain recurred after a fall 5 months before the current presentation. Paralysis of the lower limbs was not apparent after this episode. A sensory disturbance that had existed before the surgeries remained unchanged. No new lesions such as a lateral recess or foraminal stenosis, herniated nucleus pulposus, or fracture were found on radiographs or magnetic resonance images . The previous medical institution prescribed acetaminophen and tramadol for low back pain and performed a caudal epidural block with 5 ml of 1% lidocaine and dexamethasone 1.65 mg. However, neither treatment provided pain relief, and the patient was referred to our pain clinic. She had several comorbidities, including diabetes mellitus, hypertension, renal dysfunction, hypothyroidism, rheumatic arthritis, and gastroesophageal regurgitation, and was prescribed 27 different drugs by clinicians from five different facilities. Accordingly, we decided not to use additional medication for first-line therapy because of polypharmacy concerns and renal dysfunction and performed bilateral ESP block with the patient in the prone position. A convex type transducer was placed in a longitudinal orientation at the level of the L2 transverse process, 3 cm lateral to the midline. The L4 and L5 transverse processes could not be identified because of the echogenic artifacts due to the surgical instruments. The posterior surface of the L2 transverse process was identified using an aseptic technique. After the puncture point was anesthetized with 2 ml of 1% lidocaine, the needle was inserted in the plane of the ultrasound beam in a cephalad to caudal direction. Following confirmation of the needle tip on the surface of the transverse process of L2, 20 ml of 0.1875% ropivacaine (fourfold dilution of commercial product) was injected into the target plane between the erector spinae muscles and the transverse process . This procedure was repeated on the contralateral side. Twenty-five minutes later, the patient reported a warm feeling in her low back and almost complete relief from pain, which was approximately < 10% of its original severity. There was an area of diminished cold sensation extending from T12 to L5, with no change in the anterior and lateral abdomen. Unfortunately, the pinprick test was not performed. Pain relief lasted for approximately 10 h after the initial block. We repeated this procedure for a total of three times in a month. Finally, the patient reported that her daily baseline level of low back pain had diminished to < 40% of its original severity. She was satisfied with the extent of pain control and did not wish to undergo further treatments such as epiduroscopy or spinal cord stimulation (SCS).", "summary": "Here we report a case involving a 72-year-old woman who experienced recurrent low back pain after undergoing two back surgeries. She was treated with erector spinae plane (ESP) block, which affected the dorsal rami of the spinal nerves from T12 to L5. Pain relief lasted for approximately 10 h after the initial block, and successful low back pain relief was achieved after a total of three trials.", "subclaim_evaluations": [ { "subclaim": "The patient was a 72-year-old woman.", "support_label": "supported" }, { "subclaim": "She had two back surgeries.", "support_label": "supported" }, { "subclaim": "She experienced recurrent low back pain.", "support_label": "supported" }, { "subclaim": "She was treated with an erector spinae plane block.", "support_label": "supported" }, { "subclaim": "The block affected the dorsal rami of the spinal nerves.", "support_label": "supported" }, { "subclaim": "The block affected spinal nerves from T12 to L5.", "support_label": "supported" }, { "subclaim": "Pain relief lasted approximately 10 hours after the initial block.", "support_label": "supported" }, { "subclaim": "Successful low back pain relief was achieved.", "support_label": "supported" }, { "subclaim": "The treatment required a total of three trials.", "support_label": "supported" } ] }, { "id": "multiclinsum_test_2048_en.txt", "fulltext": "A 57-year-old man was referred to neuro-oncology for brain MRI findings concerning for cortical laminar necrosis in the setting of metastatic melanoma. He was originally diagnosed with Stage IIIB (pT4bN1aM0) BRAF V600E-mutated cutaneous melanoma 6 years before evaluation with positive sentinel lymph node biopsy. Brain MRI at that time was normal. He had received multiple treatments throughout the years but for the past 30 months had been treated only with encorafenib and binimetinib with stable systemic disease. His medical history was otherwise unremarkable and he had no risk factors for vascular disease.\nRoutine, asymptomatic surveillance brain MRI with contrast was obtained and was notable for gyriform T1 shortening in the right pars opercularis, new from most recent imaging performed 23 months prior . Contrast-enhanced T1-weighted imaging showed no discernable enhancement, T2-weighted sequences showed no local edema, and diffusion-weighted imaging showed no diffusion restriction. These findings were most consistent with cortical laminar necrosis from chronic infarction. Nonetheless, given his clinical history and lack of vascular risk factors, metastatic disease remained a diagnostic consideration and close interval follow-up was planned.\nRepeat MRI obtained 3 months later revealed gyral expansion in the region of the T1 shortening as well as a new contrast-enhancing adjacent nodule with vasogenic edema . Given imaging features, he underwent craniotomy revealing a subpial lesion that was grossly melanotic. The lesion followed and infiltrated gray matter in a gyriform pattern, with an adjacent melanotic nodule . A total resection was achieved utilizing subpial dissection to protect nearby Sylvian vessels. The surgical specimen showed cortical gray matter with infiltration by neoplastic cells in a primarily perivascular pattern with no definitive tumor mass. The neoplasm was composed of large cells with atypical nuclei and prominent nucleoli. The majority of the tumor cells showed melanin pigment. All these findings were consistent with a metastatic malignant melanoma. The tumor expressed the mutant BRAF V600E protein by immunohistochemistry. The patient recovered well without postoperative neurological deficit. He received Gamma Knife radiosurgery to the surgical bed with a dose of 9 Gy at the 50% isodose line.", "summary": "Here, we present a case of a 57-year-old man in whom a metastatic melanoma initially mimicked the imaging characteristics of cortical laminar necrosis.", "subclaim_evaluations": [ { "subclaim": "The patient was a 57-year-old man.", "support_label": "supported" }, { "subclaim": "The patient had metastatic melanoma.", "support_label": "supported" }, { "subclaim": "The metastatic melanoma initially mimicked the imaging characteristics of cortical laminar necrosis.", "support_label": "supported" } ] }, { "id": "multiclinsum_test_6_en.txt", "fulltext": "A 24-year-old female presented with a 1 year history of a painful, large, irregular, lobular mass rapidly growing at the nape of the neck, accompanied by decreased sensation/numbness in the C1-C2 dermatomes . Computed tomography (CT) scans of both the head and neck revealed a moderately enhancing 10-12 cm lesion (in greatest diameter) extending from skull base to the thyroid gland. It additionally involved the posterior cervical muscles, eroded through the posterior arch of atlas and occipital bone, where it exhibited both extradural/intraspinal, and intracranial extension . An incisional biopsy documented a highly vascular lesion consistent with a cellular variant of a solitary fibrous tumor (SFT) with HPC-like features. Preoperative RT was administered to reduce the size and vascularity of the tumor, and was followed by aggressive subtotal resection of an encapsulated, soft, vascular tumor. Notably, radical resection was limited by the tumor's depth and vascularity. Further postoperative RT resulted in a good clinical outcome.\nHistopathology revealed a vascular neoplasm characterized by sheets/groups of spindle/oval cells with a stag horn pattern consistent with HPC located in between plentiful of thin-walled vessels . On immunohistochemistry, consistent with the diagnosis of HPC, the tumor cells were positive for both cluster of differentiation 34 (CD34) and vimentin . The postoperative CT scan documented only a minimal amount of residual tumor (near the atlanto-occipital junction) with near complete decompression of the craniovertebral (CV) junction . Two years postoperatively, the patient remains asymptomatic and disease free (e.g., no recurrence or metastases).", "summary": "We report a case of a 24-year-old female with a rapidly growing, highly vascular swelling in nape of the neck extending deep into the craniovertebral (CV) junction accompanied by extradural/intraspinal, and intracranial involvement. An incisional biopsy revealed a cellular, highly vascular tumor with HPC-like features. The patient received preoperative RT, which reduced both the size and vascularity of the lesion, facilitating subsequent near complete resection. Further postoperative RT resulted in a good clinical outcome, with no tumor recurrence observed at 2 postoperative years.", "subclaim_evaluations": [ { "subclaim": "The patient is a 24-year-old female.", "support_label": "supported" }, { "subclaim": "The patient had a rapidly growing, highly vascular swelling in the nape of the neck.", "support_label": "supported" }, { "subclaim": "The swelling extended deep into the craniovertebral junction.", "support_label": "supported" }, { "subclaim": "The tumor had extradural/intraspinal involvement.", "support_label": "supported" }, { "subclaim": "The tumor had intracranial involvement.", "support_label": "supported" }, { "subclaim": "An incisional biopsy was performed.", "support_label": "supported" }, { "subclaim": "The biopsy revealed a cellular, highly vascular tumor.", "support_label": "supported" }, { "subclaim": "The tumor had hemangiopericytoma-like features.", "support_label": "supported" }, { "subclaim": "The patient received preoperative radiotherapy.", "support_label": "supported" }, { "subclaim": "Preoperative radiotherapy reduced the size of the lesion.", "support_label": "supported" }, { "subclaim": "Preoperative radiotherapy reduced the vascularity of the lesion.", "support_label": "supported" }, { "subclaim": "The lesion was near completely resected.", "support_label": "supported" }, { "subclaim": "The patient received further postoperative radiotherapy.", "support_label": "supported" }, { "subclaim": "The patient had no tumor recurrence at 2 postoperative years.", "support_label": "supported" } ] }, { "id": "multiclinsum_test_2526_en.txt", "fulltext": "35 years old female presented to the casualty with bilateral lower limb paralysis for 1 month following child birth, the condition occurred suddenly, it was associated with back pain and complete loss of sphintric control. On examination patient looks generally well, with normal vital signs readings, GCS 15/15, intact cranial nerves, normal power, tone and reflexes in upper limbs with intact sensation to all modalities, but lower limb showed power grade zero, hypertonia, hyper-reflexia grade 4 and positive Babinski’s sign. Sensory modalities were examined and revealed sensory impairment up to the level of umbilicus (loss of vibration and position sense), and there was mild mid-dorsal tenderness.\nPatient haematological parameters were investigated and revealed normal readings. Dorsolumber MRI was done showed T1 weighted extradural hyperintense lesion from D5 to D8 compressing the spinal cord from posterior, T2 weighted images showed the lesion which is hyperintense in relation to spinal cord and almost isointense with normal fat signals and cord myelopathic changes and contrasted MRI images showed prevalent, a little inhomogeneous contrast uptake by the lesion. Surgical intervention was done through posterior approach dorsal decompressive laminectomies and total resection of the lesion with no intraoperative significant events was achieved, and specimen was sent for histopathology .", "summary": "A case of thoracic spinal extradural angiolipoma producing acute spinal cord compression in a 35-year old housewife is presented. Patient presented with sudden onset of lower limbs paralysis and urinary incontinence for 1 month after vaginal delivery. Patient was diagnosed as dorsal spine angiolipoma which was treated surgically with excellent outcome.", "subclaim_evaluations": [ { "subclaim": "The patient is a 35-year-old housewife.", "support_label": "not_supported" }, { "subclaim": "The patient had a case of thoracic spinal extradural angiolipoma.", "support_label": "not_supported" }, { "subclaim": "The angiolipoma produced acute spinal cord compression.", "support_label": "not_supported" }, { "subclaim": "The patient presented with sudden onset of lower limbs paralysis.", "support_label": "supported" }, { "subclaim": "The patient had urinary incontinence.", "support_label": "supported" }, { "subclaim": "The symptoms lasted for 1 month.", "support_label": "supported" }, { "subclaim": "The symptoms occurred after vaginal delivery.", "support_label": "supported" }, { "subclaim": "The patient was diagnosed with dorsal spine angiolipoma.", "support_label": "not_supported" }, { "subclaim": "The patient was treated surgically.", "support_label": "supported" }, { "subclaim": "The surgical treatment had an excellent outcome.", "support_label": "not_supported" } ] }, { "id": "multiclinsum_test_520_en.txt", "fulltext": "A 56-year-old woman was referred to the emergency department due to a severe headache in the frontal area for 2 days before admission. The patient had nausea and vomiting in the morning but had no history of seizures or decreased consciousness. The examination of neurological symptoms was completely normal and showed no symptoms of meningeal irritation. The patient's vital signs were recorded as follows: blood pressure (BP)=130/85 mmHg, heart rate (HR)= 86/min, and temperature (T)=37.3 °C. In her past history, the patient had undergonetympano- mastoidectomy surgery and resection of the cholesteatoma 1 week earlier, and a canalwall down mastoidectomy (CWD) was performed due to right ear cholesteatoma. According to the information obtained from the previous surgeon, microtrauma was inflicted in the dural plate during surgery, but since no significant cerebrospinal fluid (CSF) leak occurred during the procedure, reconstruction was not necessary. After admission, examination and initial evaluation, the Mount Fuji sign was found on the brain CT scan of the patient, but no evidence of brain abscess or intracranial hemorrhage. The patient was immediately admitted to the intensive care unit (ICU).\nInitial treatments such as CBR, 30-degree head elevation, anti-fever therapy, analgesics and oxygen therapy, along with anti-compulsive drug (phenytoin), were prescribed. The patient did not undergo surgery due to a lack of neurological symptoms and a decreased level of consciousness or seizures. However, in the ICU, the patient was maintained under regular and continuous monitoring of vital and neurological signs and level of consciousness. The day after admission, the patient’s headache had completely resolved. The patient was admitted to the ICU for 5 days and was monitored for volume ofpneumocephalus every day with a CT scan. At the end of 5 days, the patient's pneumocephalus was resolved completely, and she was transferred to the ward. The patient was discharged after complete recovery.", "summary": "A 56-year-old woman was referred to the emergency department due to a severe headache in the frontal area for 2 days before admission. The patient experienced nausea and vomiting in the morning and had no history of seizures or decreased consciousness. Examination of neurological symptoms was completely normal and showed no symptoms of meningeal irritation. In terms of past history, the patient had undergone tympanomastoidectomy surgery and resection of the cholesteatoma 1 week previously. The Mount Fuji sign was found on the brain computed tomography (CT) scan of the patient. Treatments such as CBR (complete bed rest), 30-degree head elevation, anti-fever, analgesics and oxygen therapy, along with anti-compulsive drug (phenytoin), were prescribed. At the end of 5 days, the patient's pneumocephalus was resolved completely.", "subclaim_evaluations": [ { "subclaim": "The patient is a 56-year-old woman.", "support_label": "supported" }, { "subclaim": "She was referred to the emergency department.", "support_label": "supported" }, { "subclaim": "She had a severe headache in the frontal area for 2 days before admission.", "support_label": "supported" }, { "subclaim": "She experienced nausea and vomiting in the morning.", "support_label": "supported" }, { "subclaim": "She had no history of seizures.", "support_label": "supported" }, { "subclaim": "She had no history of decreased consciousness.", "support_label": "supported" }, { "subclaim": "Neurological examination was completely normal.", "support_label": "supported" }, { "subclaim": "There were no symptoms of meningeal irritation.", "support_label": "supported" }, { "subclaim": "She had undergone tympanomastoidectomy surgery 1 week previously.", "support_label": "supported" }, { "subclaim": "She had resection of the cholesteatoma 1 week previously.", "support_label": "supported" }, { "subclaim": "The Mount Fuji sign was found on the brain CT scan.", "support_label": "supported" }, { "subclaim": "CBR (complete bed rest) was prescribed.", "support_label": "supported" }, { "subclaim": "30-degree head elevation was prescribed.", "support_label": "supported" }, { "subclaim": "Anti-fever medication was prescribed.", "support_label": "supported" }, { "subclaim": "Analgesics were prescribed.", "support_label": "supported" }, { "subclaim": "Oxygen therapy was prescribed.", "support_label": "supported" }, { "subclaim": "Phenytoin was prescribed.", "support_label": "supported" }, { "subclaim": "The pneumocephalus was resolved completely after 5 days.", "support_label": "supported" } ] }, { "id": "multiclinsum_test_1348_en.txt", "fulltext": "A 76-year-old Japanese man with a history of hypertension, laryngeal cancer, chronic obstructive pulmonary disease (COPD), and type 2 diabetes mellitus developed a cerebral arteriovenous malformation hemorrhage and was hospitalized at Aichi Medical University Hospital, Japan. His vaccination history was unknown. Case characteristics and laboratory data on the first visit are summarized in Table . Following surgery for removal of the hematoma, he began rehabilitation and was encouraged to engage in early postoperative ambulation. In March, 2015, on the 66th day of hospitalization, he developed a sudden fever and exhibited a sharp decline in oxygenation.\nAt the onset of fever, the patient’s vital signs were as follows: body temperature, 37.8 °C; blood pressure, 84/41 mmHg; heart rate, 107/min; respiration rate, 30/min; and SpO2, 82% (room air). Blood gas analysis (room air) showed pH 7.538, 25.7 mmHg, 47.6 mmHg, HCO3\n− 21.4 mmol/L, and lactate 38.9 mg/dL. His level of consciousness was I-2 on the Japan Coma Scale. Physical examination showed coarse crackles and wheezes in the right lung. Based on chest radiography and computed tomography images , hospital-acquired aspiration pneumonia was diagnosed.\nPiperacillin/tazobactam 4.5 g was administered three times daily as initial treatment . Streptococcus pneumoniae infection was suspected based on a rapid identification test using a sputum smear, and a strain of S. pneumoniae was isolated from the blood culture sampled at the onset of fever. The patient was admitted to the intensive care unit and teicoplanin was added to his treatment regimen. However, his SpO2 and respiratory rate continued to be unstable. After 5 days of concomitant teicoplanin administration, the patient died.\nStreptococcus pneumoniae detected in the smear and the morphologic characteristics of the colonies on blood agar are shown in Fig. . The isolate was mucoid serotype strain 3, with a thick capsule. Antibiotic susceptibility to penicillins, cephalosporins, carbapenems, and levofloxacin was good, with resistance observed only to a macrolide (erythromycin) .", "summary": "The patient had a history of hypertension, laryngeal cancer, chronic obstructive pulmonary disease, and type 2 diabetes mellitus. Following a cerebral arteriovenous malformation hemorrhage, he underwent surgery to remove the hematoma and began rehabilitation. On day 66 of hospitalization, he suddenly developed a fever, and coarse crackles and wheezes were heard in his right lung. A diagnosis of hospital-acquired aspiration pneumonia was made, and initial treatment with piperacillin/tazobactam was started. Teicoplanin was added after S. pneumoniae was isolated from the blood culture, however, the patient died 5 days later. The S. pneumoniae detected in the sputum smear was serotype 3, showed mucoid colonies and susceptibility to penicillins, cephalosporins, carbapenems, and levofloxacin, but resistance to erythromycin.", "subclaim_evaluations": [ { "subclaim": "The patient had a history of hypertension.", "support_label": "supported" }, { "subclaim": "The patient had a history of laryngeal cancer.", "support_label": "supported" }, { "subclaim": "The patient had a history of chronic obstructive pulmonary disease.", "support_label": "supported" }, { "subclaim": "The patient had a history of type 2 diabetes mellitus.", "support_label": "supported" }, { "subclaim": "The patient had a cerebral arteriovenous malformation hemorrhage.", "support_label": "supported" }, { "subclaim": "The patient underwent surgery to remove the hematoma.", "support_label": "supported" }, { "subclaim": "The patient began rehabilitation.", "support_label": "supported" }, { "subclaim": "On day 66 of hospitalization, the patient suddenly developed a fever.", "support_label": "supported" }, { "subclaim": "Coarse crackles and wheezes were heard in the right lung.", "support_label": "supported" }, { "subclaim": "A diagnosis of hospital-acquired aspiration pneumonia was made.", "support_label": "supported" }, { "subclaim": "Initial treatment with piperacillin/tazobactam was started.", "support_label": "supported" }, { "subclaim": "Teicoplanin was added after S. pneumoniae was isolated from the blood culture.", "support_label": "supported" }, { "subclaim": "The patient died 5 days after teicoplanin was added.", "support_label": "supported" }, { "subclaim": "The S. pneumoniae detected in the sputum smear was serotype 3.", "support_label": "supported" }, { "subclaim": "The S. pneumoniae showed mucoid colonies.", "support_label": "supported" }, { "subclaim": "The S. pneumoniae was susceptible to penicillins.", "support_label": "supported" }, { "subclaim": "The S. pneumoniae was susceptible to cephalosporins.", "support_label": "supported" }, { "subclaim": "The S. pneumoniae was susceptible to carbapenems.", "support_label": "supported" }, { "subclaim": "The S. pneumoniae was susceptible to levofloxacin.", "support_label": "not_supported" }, { "subclaim": "The S. pneumoniae was resistant to erythromycin.", "support_label": "supported" } ] }, { "id": "multiclinsum_test_2934_en.txt", "fulltext": "A 27-year-old man, a laborer from Vietnam, sustained head injury and severe pain as well as swelling and deformity in both lower limbs as a result of a road traffic accident on July 7, 2018.\nThe patient had no medical history.\nThe patient had no special past illness.\nThe patient had no history of drug allergies, smoking, or drinking, and no relevant family history.\nThe patient was brought by ambulance to our emergency room (ER) for treatment. A general examination revealed that the patient had a head injury with a Glasgow Coma Scale score of E4V5M3 and clear consciousness, and he was able to communicate. The initial vitals revealed hypotension (82/55 mmHg), tachycardia (107 beats/min), and a respiration rate of 26 breaths/min. During the clinical physical examination, the patient was bedridden and was incapable of stepping on or making small motions with either foot. Multiple bleeding lacerations were observed on the left forehead (3.0 × 2.0 cm), lower lip (2.0 × 1.0 cm), anterior neck (4.0 × 1.0 cm), left anterior thigh (2.5 × 2.0 cm), left posterior heel (4.0 × 1.0 cm), and right posterior thigh (3.0 × 1.0 cm). Multiple abrasions were also identified on his face, body and limbs. The thighs and lower limbs appeared deformed, with free floating bone fragments. Distal pulses, including in the bilateral popliteal artery, posterior tibial artery, and pedal dorsal artery, were palpable.\nRoutine blood tests revealed that hemoglobin was 9.5 mg/dL, and other blood chemistry results, including for liver and kidney function and electrolyte assessment, were all within the normal range.\nA plain radiograph revealed displaced bilateral femoral, tibial, and fibular midshaft fractures . Computed tomography (CT) identified no notable intracranial, intrathoracic, or intra-abdominal bleeding.", "summary": "A 27-year-old man sustained multiple injuries when the electric motorcycle he was riding was hit by a van. His injuries included traumatic hypovolemic shock, comminuted and open type II fractures of the left femoral shaft, fracture of the right femoral shaft, comminuted fracture of the bilateral tibial and fibular shaft, and multiple lacerations and abrasions on his forehead, lower lip, neck and limbs. The diagnosis was simultaneous bilateral floating knee complicated with soft tissue injuries. After emergency treatment and the exclusion of life-threating complications, open reduction and internal fixation were successfully performed using plates and screws in the bilateral femoral and tibial shafts.", "subclaim_evaluations": [ { "subclaim": "The patient is a 27-year-old man.", "support_label": "supported" }, { "subclaim": "The patient was riding an electric motorcycle.", "support_label": "not_supported" }, { "subclaim": "The motorcycle was hit by a van.", "support_label": "not_supported" }, { "subclaim": "The patient sustained multiple injuries.", "support_label": "supported" }, { "subclaim": "The patient had traumatic hypovolemic shock.", "support_label": "supported" }, { "subclaim": "The patient had comminuted and open type II fractures of the left femoral shaft.", "support_label": "not_supported" }, { "subclaim": "The patient had a fracture of the right femoral shaft.", "support_label": "supported" }, { "subclaim": "The patient had comminuted fractures of the bilateral tibial and fibular shafts.", "support_label": "supported" }, { "subclaim": "The patient had multiple lacerations and abrasions on his forehead.", "support_label": "supported" }, { "subclaim": "The patient had multiple lacerations and abrasions on his lower lip.", "support_label": "supported" }, { "subclaim": "The patient had multiple lacerations and abrasions on his neck.", "support_label": "supported" }, { "subclaim": "The patient had multiple lacerations and abrasions on his limbs.", "support_label": "supported" }, { "subclaim": "The diagnosis was simultaneous bilateral floating knee.", "support_label": "supported" }, { "subclaim": "The diagnosis included soft tissue injuries.", "support_label": "supported" }, { "subclaim": "Emergency treatment was provided.", "support_label": "supported" }, { "subclaim": "Life-threatening complications were excluded.", "support_label": "supported" }, { "subclaim": "Open reduction and internal fixation were performed.", "support_label": "not_supported" }, { "subclaim": "The procedure was performed on the bilateral femoral shafts.", "support_label": "supported" }, { "subclaim": "The procedure was performed on the bilateral tibial shafts.", "support_label": "not_supported" }, { "subclaim": "Plates and screws were used for fixation.", "support_label": "not_supported" } ] }, { "id": "multiclinsum_test_1653_en.txt", "fulltext": "A 62-year-old man was treated with pembrolizumab for right lung adenocarcinoma, which showed high PD-L1 expression (80%), with multiple intestinal, lymph node, and bone metastases. The TNM classification for NSCLC was cT2N3M1c (OSS, LYM, PER, OTH), stage IVB (eighth edition). Tumor reduction was observed, but pembrolizumab was stopped after three courses owing to drug-induced pneumonitis. Dexamethasone was used for the treatment of pneumonitis. One month after drug withdrawal, the patient was transported to the emergency department of our hospital with the complaint of severe stomachache. On physical examination, he had a rigid abdomen and generalized tenderness. His blood pressure was in the normal range (110/82 mmHg), the heart rate was elevated but regular at 100 beats per minute, and the body temperature was elevated at 38.9 °C. The peripheral capillary oxygen saturation was 98% at room air. Laboratory evaluation showed a high inflammatory response with a white blood cell count of 18,200/mm3 and C-reactive protein level of 20.8 mg/dL. CT examination showed abdominal free air and ascites with perforation of the existing lung adenocarcinoma metastasis . We diagnosed bowel perforation with acute diffuse peritonitis. Emergency laparotomy was performed, and multiple small intestinal metastasis with mesenteric lymph node metastasis and ascites containing intestinal fluid were observed. The perforation site was located in the metastatic jejunum about 40 cm on the anal side from Treitz’s ligament. We resected this part about 20 cm and anastomosed with functional end-to-end anastomosis. There was no complication after surgery, and he was discharged on post-operative day 15. Pathological examination indicated lung adenocarcinoma metastasis in the perforated intestine, and the metastasis was partly scarred owing to the effect of pembrolizumab . Tumor cells in the perforation site had a high degree of degeneration and necrosis, and the pathological response for the efficacy of pembrolizumab was grade 1b (Japanese Classification of the Colorectal Carcinoma, seventh edition) . In the perforated part, the tumor cells were observed in all layers, but in the vicinity on the serosa side. Inflammatory change due to enteritis was not found in this site. Pembrolizumab was re-administrated about 1 month after discharge. To prevent drug-induced pneumonitis, dexamethasone was used daily.", "summary": "A 62-year-old man was treated by pembrolizumab for PD-L1 highly expressed lung adenocarcinoma, with multiple metastasis (small intestinal, lymph nodes, and bone). The treatment was stopped owing to drug-induced pneumonitis. One month after drug withdrawal, the patient visited the emergency department of our hospital with the complaint of severe stomachache. He had a rigid abdomen and generalized tenderness, and computed tomography scans showed free air within the abdomen. We diagnosed bowel perforation and performed emergency surgery. Surgical findings revealed multiple small intestine metastasis and mesenteric lymph node metastasis. Perforation was found in the metastatic site in the jejunum located around 40 cm anal to Treitz's ligament. This perforated part was resected, and functional end-to-end anastomosis was performed using linear staplers. The post-operative course was uneventful. Pathological examination revealed lung adenocarcinoma metastasis at the perforation site, and the effectiveness of pembrolizumab was grade 1b (Japanese Classification of the Colorectal Carcinoma, seventh edition).", "subclaim_evaluations": [ { "subclaim": "The patient is a 62-year-old man.", "support_label": "supported" }, { "subclaim": "The patient was treated with pembrolizumab.", "support_label": "supported" }, { "subclaim": "The patient had PD-L1 highly expressed lung adenocarcinoma.", "support_label": "supported" }, { "subclaim": "The patient had multiple metastases.", "support_label": "supported" }, { "subclaim": "The patient had small intestinal metastasis.", "support_label": "supported" }, { "subclaim": "The patient had lymph node metastasis.", "support_label": "supported" }, { "subclaim": "The patient had bone metastasis.", "support_label": "supported" }, { "subclaim": "The treatment was stopped due to drug-induced pneumonitis.", "support_label": "supported" }, { "subclaim": "One month after drug withdrawal, the patient visited the emergency department with severe stomachache.", "support_label": "supported" }, { "subclaim": "Computed tomography scans showed free air within the abdomen.", "support_label": "supported" }, { "subclaim": "The diagnosis was bowel perforation.", "support_label": "supported" }, { "subclaim": "Emergency surgery was performed.", "support_label": "supported" }, { "subclaim": "Surgical findings revealed multiple small intestine metastases.", "support_label": "supported" }, { "subclaim": "Surgical findings revealed mesenteric lymph node metastasis.", "support_label": "supported" }, { "subclaim": "Perforation was found in the metastatic site in the jejunum.", "support_label": "supported" }, { "subclaim": "The perforated part was resected.", "support_label": "supported" }, { "subclaim": "Functional end-to-end anastomosis was performed using linear staplers.", "support_label": "not_supported" }, { "subclaim": "The post-operative course was uneventful.", "support_label": "supported" }, { "subclaim": "Pathological examination revealed lung adenocarcinoma metastasis at the perforation site.", "support_label": "supported" }, { "subclaim": "The effectiveness of pembrolizumab was grade 1b according to the Japanese Classification of the Colorectal Carcinoma, seventh edition.", "support_label": "supported" } ] }, { "id": "multiclinsum_test_2019_en.txt", "fulltext": "A 74-year-old previously healthy man was referred to our institution for repeated palpitations over 6 months. A Holter electrocardiogram (ECG) from the local hospital showed persistent AT. No oral anti-arrhythmia drugs were prescribed. The initial workup included baseline ECG, routine blood tests, chest X-ray, echocardiogram, and coronary angiography. There was frequent unifocal initiating AT with a P-wave morphology of positive amplitude in I, II, III, aVF, and V1 .\nThe patient underwent an electrophysiological study and ablation. Endocardial mapping of the atrium was performed using a PentaRay catheter (Biosense Webster, Inc., CA, USA) and a smart-touch contact force (CF)-sensing catheter (Biosense Webster, Inc., CA, USA) with the CARTO mapping system (Carto, Biosense Webster). Spontaneous AT was identified and mapped throughout the procedure using activation mapping, voltage mapping, and ripple mapping. Intracardiac electrophysiology during AT [cycle length (CL) 184 ms] showed atrial signals with an eccentric pattern of atrial activation on the coronary sinus catheter . Further activation mapping showed the earliest activation zone of AT originated in the right atrial FO. Ripple mapping showed activation progressing from the FO to both the right atrium and left atrium . Voltage mapping revealed no low-voltage regions in either atrium .\nIn the FO, further high-density mapping (HDM) using the PentaRay catheter and point-to-point mapping using the CF-sensing catheter (Biosense Webster, Inc., CA, USA) demonstrated significantly long-duration fractionated electrograms covering a considerable percentage of the CL of the tachycardia within a localized region . About 107 points at 12 cm2 were taken for the map. The colours of the wavefront on the activation maps can be tracked by following the regions where red meets purple . Concealed entrainment was fulfilled only at the FO, which implied the tachycardia mechanism is micro-reentrant in nature.\nA radiofrequency catheter ablation (RFCA) current was delivered at 30 W in power-controlled mode at 43°C and a normal saline velocity of 17 mL per minutes. The RFCA was delivered to the middle of the micro-reentrant circuit, terminating the AT immediately after 3 s (, Video S2). No AT was induced during programme stimulation and isoproterenol infusion (10 µg/min). The patient had no further episodes of AT over the ensuing 12 months until he was discharged to his home without antiarrhythmic drugs.", "summary": "A 74-year-old man presented with paroxysmal atrial tachycardia (AT) presenting as palpitations. He was evaluated by an electrophysiological examination using a high-density CARTO mapping system. The mapping results showed the AT with a cycle length of 184 ms was focused on his right atrial fossa ovalis (FO). In this small area, the high-density mapping demonstrated a significant micro-reentrant tachycardia. Radiofrequency ablation at the centre of the micro-reentrant circuit successfully terminated the AT. No recurrences were observed during a 12-month follow-up.", "subclaim_evaluations": [ { "subclaim": "The patient is a 74-year-old man.", "support_label": "supported" }, { "subclaim": "He presented with paroxysmal atrial tachycardia.", "support_label": "supported" }, { "subclaim": "The tachycardia was associated with palpitations.", "support_label": "supported" }, { "subclaim": "An electrophysiological examination was performed.", "support_label": "supported" }, { "subclaim": "A high-density CARTO mapping system was used.", "support_label": "supported" }, { "subclaim": "The tachycardia had a cycle length of 184 ms.", "support_label": "supported" }, { "subclaim": "The tachycardia was focused on the right atrial fossa ovalis.", "support_label": "supported" }, { "subclaim": "The high-density mapping showed a significant micro-reentrant tachycardia.", "support_label": "supported" }, { "subclaim": "Radiofrequency ablation was performed at the center of the micro-reentrant circuit.", "support_label": "supported" }, { "subclaim": "The ablation successfully terminated the tachycardia.", "support_label": "supported" }, { "subclaim": "No recurrences were observed during a 12-month follow-up.", "support_label": "supported" } ] }, { "id": "multiclinsum_test_2618_en.txt", "fulltext": "A 77-year-old Japanese woman was diagnosed with malignant melanoma in the right sinonasal cavity using biopsy approximately three years ago. She complained of nasal bleeding at that time. She underwent proton beam radiation therapy with sequential chemotherapy; however, she experienced double vision, and 1.5 years later, MRI revealed a local recurrence. After several courses of additional chemotherapy, the disease remained stable for the last 1.5 years. She underwent follow-up PET–CT and FDG uptake was detected at the gallbladder . Hematological examination revealed no specific findings. Contrast abdominal CT revealed an early enhanced mass in the gallbladder, and the enhancement persisted in the equilibrium phase . On MRI, the tumor showed low signal intensity on T1-weighted images and slightly high intensity on T2-weighted images . Endoscopic ultrasonography (EUS) showed no apparent tumor infiltration to the liver.\nThe patient did not present with any symptoms. Because of the remaining nasal melanoma, surgical indication for the gallbladder tumor was controversial. We, however, recommended surgical treatment and she agreed for fear of its malignant potential. The primary preoperative diagnosis of the lesion was gallbladder cancer, and the secondary assessment was metastatic melanoma. Her general condition was good. After obtaining informed consent, which included advisement of the risk of relapse of nasal melanoma, we performed laparotomy and cholecystectomy with partial liver resection. In addition, lymphadenectomy of the hepatoduodenal ligament was performed. No ascites or macroscopic peritoneal dissemination was observed, and the tumor was localized in the gallbladder. The distal margin of the cystic duct was cancer free and the common bile duct was preserved. The tumor was soft, whitish, and measured 7.5 cm × 5 cm . Microscopically, it was diagnosed as a poorly differentiated malignant melanoma. Immunohistochemical examination revealed that the tumor was not similar to nasal melanoma, i.e., HMB-45 staining was far less positive in the gallbladder tumor than in the nasal tumor . The tumor cells reached the subserosal layer with mild vascular involvement, and the lymph nodes gave negative results for metastasis. No gallstones were observed. The postoperative course was uneventful. No distal recurrence has been detected for more than 13 months after surgery.", "summary": "A 77-year-old Japanese woman diagnosed with malignant melanoma of the left sinonasal cavity three years ago underwent follow-up PET-CT and FDG uptake was detected only at the gallbladder. The nasal melanoma had been stable for the last 1.5 years after chemoradiation and her general condition was good. Cholecystectomy was performed with partial liver resection. Lymphadenectomy of the hepatoduodenal ligament was also performed. The tumor was soft and whitish, and was microscopically diagnosed as a poorly differentiated malignant melanoma that was not similar to the nasal cavity melanoma. No further metastasis is observed for more than 13 months after surgery.", "subclaim_evaluations": [ { "subclaim": "The patient is a 77-year-old Japanese woman.", "support_label": "supported" }, { "subclaim": "She was diagnosed with malignant melanoma of the left sinonasal cavity three years ago.", "support_label": "not_supported" }, { "subclaim": "Follow-up PET-CT showed FDG uptake only at the gallbladder.", "support_label": "supported" }, { "subclaim": "The nasal melanoma had been stable for the last 1.5 years after chemoradiation.", "support_label": "supported" }, { "subclaim": "Her general condition was good.", "support_label": "supported" }, { "subclaim": "Cholecystectomy was performed.", "support_label": "supported" }, { "subclaim": "Partial liver resection was performed.", "support_label": "supported" }, { "subclaim": "Lymphadenectomy of the hepatoduodenal ligament was performed.", "support_label": "supported" }, { "subclaim": "The tumor was soft and whitish.", "support_label": "supported" }, { "subclaim": "The tumor was microscopically diagnosed as a poorly differentiated malignant melanoma.", "support_label": "supported" }, { "subclaim": "The gallbladder tumor was not similar to the nasal cavity melanoma.", "support_label": "supported" }, { "subclaim": "No further metastasis is observed for more than 13 months after surgery.", "support_label": "supported" } ] }, { "id": "multiclinsum_test_2325_en.txt", "fulltext": "The patient was an 84-year-old man who was admitted to the emergency room with a 24-h history of acute colicky abdominal pain. He denied other signs or symptoms. The relevant surgical history included old appendectomy and inguinal hernioplasty. The patient's medical history includes coronary artery disease and atherosclerosis, despite an otherwise healthy status. The patient was hemodynamically stable and in good general condition. Abdominal palpation led to pain in the left lower abdominal quadrant with no signs of peritoneal irritation. Abdominal computed tomography (CT) revealed small-bowel loops with multiple air-fluid levels and dilated stomach with a large air-fluid level . Laboratory tests showed no significant alterations.\nDecompression with a nasogastric tube was performed, and 1250 mL of light yellow fluid was evacuated. However, the symptoms persisted and he was admitted to the surgery department for further diagnostic testing, observation, and treatment. Despite stable vital signs, the patient experienced mild residual pain during palpation without abdominal distension. The patient stated that he periodically experienced mild abdominal pain for most of his adult life. Examination with an oral water-soluble contrast revealed small-bowel obstruction which remained unresolved over several hours of observation, leading to the suspicion of adhesive small-bowel obstruction . After receiving information regarding diagnostic laparoscopy and the potential for further surgical treatment based on intraoperative evaluation, the patient provided consent to the procedure.\nLaparoscopy revealed multiple diverticula in the proximal small intestine with distinctly dilated jejunal loops. Given the extent of the disease and the high iatrogenic injury risk, the procedure was converted to open surgery. A midline laparotomy was performed, and chronic rotation of the mesentery (volvulus) was observed. Derotation of the small intestinal loops was performed. Further examination revealed extensive diverticulosis in the proximal 2-m section of the jejunum starting approximately 20 cm from Treitz's ligament . Chronic fibrous adhesions and strictures were also observed in the mesentery and the small intestine. The affected small bowel was resected to prevent recurrent volvulus and other complications, such as diverticulitis, perforation, and bleeding. Following the resection of the jejunal segment with multiple large diverticula, side-to-side entero–entero anastomosis was performed. No diverticula were observed in the remaining bowel.\nThe postoperative period was uneventful, and the patient was discharged from the hospital on postoperative day 6. The histopathologic evaluation of the resected material confirmed substantial jejunal diverticulosis with chronic fibrosis, adhesions, and strictures.", "summary": "An 84-year-old man was admitted to the emergency room with a 24-h history of acute colicky abdominal pain. He denied other signs or symptoms. The preoperative diagnosis based on physical and radiologic evaluations was challenging, and only diagnostic laparoscopy revealed extensive small-bowel diverticulosis. Midline laparotomy was performed as definitive surgery, revealing diverticulosis in the proximal 2-m section of the jejunum, starting approximately 20 cm from Treitz's ligament; the affected section was resected. The postoperative recovery was excellent. The histopathologic report confirmed substantial jejunal diverticulosis with chronic fibrosis, adhesions, and strictures.", "subclaim_evaluations": [ { "subclaim": "The patient is an 84-year-old man.", "support_label": "supported" }, { "subclaim": "He was admitted to the emergency room.", "support_label": "supported" }, { "subclaim": "He had a 24-hour history of acute colicky abdominal pain.", "support_label": "supported" }, { "subclaim": "He denied other signs or symptoms.", "support_label": "supported" }, { "subclaim": "The preoperative diagnosis was challenging.", "support_label": "supported" }, { "subclaim": "Diagnostic laparoscopy revealed extensive small-bowel diverticulosis.", "support_label": "supported" }, { "subclaim": "Midline laparotomy was performed as definitive surgery.", "support_label": "supported" }, { "subclaim": "The affected section of the jejunum was resected.", "support_label": "supported" }, { "subclaim": "The histopathologic report confirmed substantial jejunal diverticulosis.", "support_label": "supported" }, { "subclaim": "The histopathologic report showed chronic fibrosis.", "support_label": "supported" }, { "subclaim": "The histopathologic report showed adhesions.", "support_label": "supported" }, { "subclaim": "The histopathologic report showed strictures.", "support_label": "supported" }, { "subclaim": "The postoperative recovery was excellent.", "support_label": "supported" } ] }, { "id": "multiclinsum_test_541_en.txt", "fulltext": "A 35-year-old Han Chinese male football player presented with abnormal ECGs for 8 years without any evident subjective discomfort. The patient recently complained about slight exertional dyspnea with reduced sport/physical tolerance and was admitted to our hospital. This patient had been employed as a professional football player from the age of 10 years and had been a physical education teacher from the age of 26 years. He was a longtime local resident and never went to any affected areas (areas with high prevalence of infectious diseases). He reported being formerly healthy without any medical histories or current comorbidities, and he reported taking no medications. He has smoked 20 cigarettes per day for 7 years and consumed alcohol for 10 years at 100 to 250 g per day. His parents were healthy, and his family history was unremarkable. His physical examination revealed no abnormal findings. His body temperature was 36.5 °C, blood pressure was 121/73 mmHg, respiratory rate was 18 breaths/min, pulse was 69/min, heart rate was 70 beats/min, and reflexes were normal. He had no pathology reflex, and his body mass index was 22.81 kg/m2. Laboratory evaluation revealed slightly elevated cardiac troponin T level of 0.017 ng/ml, N-terminal probrain natriuretic peptide level of 291.80 pg/ml, and C-reactive protein level of 0.40 mg/L. The patient’s blood lipid levels, liver function, and renal function were within the normal range with glutamic oxaloacetic transaminase level of 23 U/L, glutamic-pyruvic transaminase level of 31 U/L, alkaline phosphatase level of 84 U/L, total protein level of 67.9 g/L, albumin level of 41 g/L, globulin level of 26.9 g/L, total cholesterol level of 4.01 mmol/L, triglyceride level of 1.42 mmol/L, high-density lipoprotein level of 1.08 mmol/L, low-density lipoprotein level of 2.14 mmol/L, uric acid level of 353 μmol/L, epidermal growth factor receptor level of 105.48 ml/min/1.73 m2; serum K+ level of 4.05 mmol/L, serum Ca2+ level of 2.16 mmol/L, serum Mg2+ level of 0.88 mmol/L, and serum Na+ level of 141 mmol/L. The results of routine blood test and urinalysis were negative, thyroid function was normal, and microorganisms were not detected. Chest radiography showed an apparently normal morphology of the heart and lungs . ECGs revealed progressively deepened and widened Q waves on the II, III, and avF leads and contiguous TWIs on the I and avL leads . Echocardiography revealed an increasingly thickened interventricular septum from 10 mm to 13 mm, an enlarged left atrium and ventricle, and a reduced left ventricular ejection fraction from 73% to 63% . Coronary angiography (CAG) was performed and showed no distinct stenosis. Emission computed tomography (ECT) revealed mild myocardial ischemia of the left ventricular inferior wall . All of these clinical tests supported the diagnosis of HCM, which became gradually evident with time. For further identification, we proposed other examination techniques for this patient, including cardiac magnetic resonance imaging (CMRI) to better evaluate the left ventricular wall thickness and to identify potential areas of myocardial fibrosis, Holter monitor recordings and an exercise test to evaluate possible “dynamic” changes of repolarization abnormalities, as well as genetic testing. However, the patient refused all of these suggestions and was discharged. In the subsequent follow-up visits at 1 month, 3 months, and 6 months after discharge, the patient showed poor compliance and was eventually lost to follow-up.", "summary": "A young Han Chinese male football player had abnormal electrocardiograms for 8 years without any subjective discomfort. Electrocardiograms revealed that T-wave inversions increased from 1 mm to a maximum of 5 mm on lead I and fluctuated around 5 mm on lead avL. Q-wave duration ranged from 40 ms to 60 ms, its depth increased to a maximum of 8 mm and was much greater than 40% of the R waves in depth in II, III, and avF leads. Echocardiography showed increasingly thickened interventricular septum from 10 mm to 13 mm, enlarged left atrium and ventricle, and reduced left ventricular ejection fraction. Coronary angiography showed no distinct stenosis. Emission computed tomography revealed mild myocardial ischemia of the left ventricular inferior wall. These unusual electrocardiogram manifestations were initially regarded as benign alterations of a highly trained athlete. Upon reviewing the clinical information and the newest criteria for electrocardiographic interpretation in athletes, hypertrophic cardiomyopathy was identified. The misreading of electrocardiograms is not uncommon, thus predisposing such patients to high susceptibility to exercise-induced sudden cardiac death.", "subclaim_evaluations": [ { "subclaim": "The patient is a young Han Chinese male football player.", "support_label": "supported" }, { "subclaim": "The patient had abnormal electrocardiograms for 8 years.", "support_label": "supported" }, { "subclaim": "The patient had no subjective discomfort.", "support_label": "supported" }, { "subclaim": "T-wave inversions increased from 1 mm to a maximum of 5 mm on lead I.", "support_label": "not_supported" }, { "subclaim": "T-wave inversions fluctuated around 5 mm on lead avL.", "support_label": "not_supported" }, { "subclaim": "Q-wave duration ranged from 40 ms to 60 ms.", "support_label": "not_supported" }, { "subclaim": "Q-wave depth increased to a maximum of 8 mm.", "support_label": "not_supported" }, { "subclaim": "Q-wave depth was much greater than 40% of the R waves in depth in II, III, and avF leads.", "support_label": "not_supported" }, { "subclaim": "Echocardiography showed an interventricular septum thickness increasing from 10 mm to 13 mm.", "support_label": "supported" }, { "subclaim": "Echocardiography showed an enlarged left atrium.", "support_label": "supported" }, { "subclaim": "Echocardiography showed an enlarged left ventricle.", "support_label": "supported" }, { "subclaim": "Echocardiography showed reduced left ventricular ejection fraction.", "support_label": "supported" }, { "subclaim": "Coronary angiography showed no distinct stenosis.", "support_label": "supported" }, { "subclaim": "Emission computed tomography revealed mild myocardial ischemia of the left ventricular inferior wall.", "support_label": "supported" }, { "subclaim": "The unusual electrocardiogram manifestations were initially regarded as benign alterations of a highly trained athlete.", "support_label": "not_supported" }, { "subclaim": "Hypertrophic cardiomyopathy was identified after reviewing the clinical information and the newest criteria for electrocardiographic interpretation in athletes.", "support_label": "supported" }, { "subclaim": "Misreading of electrocardiograms is not uncommon.", "support_label": "not_supported" }, { "subclaim": "Misreading of electrocardiograms predisposes patients to high susceptibility to exercise-induced sudden cardiac death.", "support_label": "not_supported" } ] }, { "id": "multiclinsum_test_2022_en.txt", "fulltext": "A 30-year-old Han Chinese man was riding his motorcycle at 80.5km/hour when he collided with an oncoming car. He complained of back pain and right shoulder pain and was admitted to a local hospital. He sustained double inferior lung contusion with a few hemothoraces, fractures of right clavicle and vertebrae T6 to T7 inclusive. After 6 hours, he was transferred to our hospital. On clinical examination, there was no neurological deficit. A three-dimensional reconstruction of computed tomography showed spinal fracture-dislocation of T6 to T7 , a fracture of right clavicle whereas fracture of ribs was not found , magnetic resonance imaging showed spinal fracture-dislocation of T6 to T7 , horizontal computed tomography scans showed a large bilateral hemothorax , fractures of bilateral pedicles of vertebral arch , three vertebral levels in one cut , and anteroposterior thoracic spine plain X-ray showed spinal fracture-dislocation of T6 to T7 and realignment of his fractured-dislocated spine .\nDespite the normal neurological systems below T7, the spine was considered unstable and an operation was planned. Chest drains were inserted bilaterally. A day later, the patient was put in the prone position under general anesthesia, the fascia was opened and his paravertebral muscles were dissected following a midline vertical incision of T4 to T11; the right pedicle of the T8 vertebra and the right lamina of the T6 vertebra were found to be fractured. Laminectomy of the T6 to T7 vertebra was done. The dura and spinal cord were found to be normal. Then the spinal canal was examined with a rubber catheter and found to be good. Transpedicular screws were put in the T5, T6, T9 and T10 vertebrae. Realignment of the thoracic spine was achieved with rods. Bony fusion of the transverse processes of the T5, T6, T7 and T8 vertebrae was done. The fracture of his right clavicle was also reduced and autologous bone graft was performed too. His nervous system was intact postoperatively. He was discharged on the 10th day after his operation. He was very well at the follow-up examination 3 months later.", "summary": "A 30-year-old Han Chinese man had T6 to T7 vertebral fracture and anterolateral dislocation without neurological symptoms and costal fractures. The three-dimensional reconstruction by computed tomography and magnetic resonance imaging indicated the injuries in detail. A patient with thoracic spinal fracture-dislocation without neurological symptoms inclines to further dislocation of the spine and secondary neurological injury; therefore, laminectomy, reduction and internal fixations with rods and screws were done. The outcome was good. Severe spinal fracture-dislocation without neurological symptoms should be evaluated in detail, especially with three-dimensional reconstruction by computed tomography. Although treatment is individualized, reduction and internal fixation are advised for the patient if the condition is suitable for operation.", "subclaim_evaluations": [ { "subclaim": "The patient is a 30-year-old Han Chinese man.", "support_label": "supported" }, { "subclaim": "The patient had T6 to T7 vertebral fracture.", "support_label": "supported" }, { "subclaim": "The patient had anterolateral dislocation.", "support_label": "not_supported" }, { "subclaim": "The patient had no neurological symptoms.", "support_label": "supported" }, { "subclaim": "The patient had costal fractures.", "support_label": "not_supported" }, { "subclaim": "Three-dimensional reconstruction by computed tomography was performed.", "support_label": "supported" }, { "subclaim": "Three-dimensional reconstruction by magnetic resonance imaging was performed.", "support_label": "not_supported" }, { "subclaim": "The three-dimensional reconstructions indicated the injuries in detail.", "support_label": "supported" }, { "subclaim": "A patient with thoracic spinal fracture-dislocation without neurological symptoms inclines to further dislocation of the spine.", "support_label": "supported" }, { "subclaim": "A patient with thoracic spinal fracture-dislocation without neurological symptoms inclines to secondary neurological injury.", "support_label": "supported" }, { "subclaim": "Laminectomy was performed.", "support_label": "supported" }, { "subclaim": "Reduction was performed.", "support_label": "supported" }, { "subclaim": "Internal fixation with rods and screws was performed.", "support_label": "supported" }, { "subclaim": "The outcome was good.", "support_label": "supported" }, { "subclaim": "Severe spinal fracture-dislocation without neurological symptoms should be evaluated in detail.", "support_label": "supported" }, { "subclaim": "Three-dimensional reconstruction by computed tomography is advised for evaluation.", "support_label": "supported" }, { "subclaim": "Treatment is individualized.", "support_label": "supported" }, { "subclaim": "Reduction and internal fixation are advised if the condition is suitable for operation.", "support_label": "supported" } ] }, { "id": "multiclinsum_test_3178_en.txt", "fulltext": "A 74-year-old woman was referred from the Department of Dermatology and Venereology to the Department of Oral Medicine Dr. Hasan Sadikin Hospital, Bandung. The patient has been hospitalized for 4 days and has been given dexamethasone 5 mg intravenously, cetirizine 10 mg tablets, and clindamycin tablets 300 mg. Based on the anamnesis, blisters on the skin that felt burning, sore, and itchy first appeared 1 week ago. Complaints of the painful canker sores in the oral cavity began to appear 2 days ago. The patient experienced of intense pain during the day. She has no medical history of any systemic disease and does not take any medication. Extraoral examination revealed a symmetrical face and the regional lymph nodes were not palpable and painless. She had multiple crusts on the neck, buttocks, and upper and lower extremities.\n\nIntraoral examination showed erosion covered by a yellowish white layer on the right and left buccal mucosa, haemorrhagic purpura on the right and left buccal mucosa and right lateral tongue, an ulcer with a diameter of 0.5 cm on the left lateral border of the tongue, and the root remnants of 12, 14, 15, 16, 17, 26, 27, 33, 34, 35, and 36 teeth. Hematology tests revealed increased values of leukocytes (15.93 x 103/µL), eosinophils (6%), and segmental neutrophils (77%). A skin biopsy of the lesion on the left thigh was performed to establish a definitive diagnosis. The results of histopathological examination showed a formation of a subepidermal blister containing eosinophil and neutrophil cells.\n\nBased on anamnesis, clinical examination, and appropriate investigations, the definitive diagnosis was oral lesions associated with dermatitis herpetiformis with a differential diagnosis of pemphigoid bullosa and linear IgA dermatoses. Additional diagnoses were exfoliative cheilitis, chronic traumatic ulcer on the left lateral border of the tongue, chronic apical periodontitis et causa the root remnants of 12, 14, 15, 16.17, 26, 27, 33, 34, 35, 36, and generalized chronic marginal gingivitis. The therapies provided by the Department of Oral Medicine including 0.025% hyaluronic acid mouthwash and petroleum jelly. Patients were instructed to brush their teeth regularly, not consume gluten-containing foods, rinse their mouths using 0.025% hyaluronic acid mouthwash three times a day, and apply petroleum jelly to moisturize the lips. Patients are also advised to do scaling and extraction of the tooth remnants of the upper and lower teeth. The prognosis of this case is good.\n\nThe oral lesions showed significant improvement at the second visit, 10 days after treatment. Erosive lesions in the oral cavity began to heal. She felt no pain at all and had no difficulties in eating solid foods. The patient uses 0.025% hyaluronic acid mouthwash and petroleum jelly regularly.\n\nThe patient was being infected with COVID-19 two months later and was treated in the COVID-19 isolation room at the Hasan Sadikin General Hospital in Bandung for 1 week. She experienced the typical symptoms of COVID-19 (fever, muscle aches, and shortness of breath) and decreased oxygen saturation (87.3%). Acute exacerbations of dermatitis herpetiformis lesions on the skin and perioral occurred after the patient was infected with COVID-19. Extraoral examination revealed crusts on the perioral, erosive lesions covered by white-yellowish plaque on the vermillion border of the upper lip. Laboratory tests revealed anti-SARS-CoV-2 IgG S-RBD values (>40,000 AU/mL), eosinophils (6%), total eosinophils (0.50 x 103/µL), C-reactive protein (2 mg/dl), quantitative D-dimer (3.72 µg/mL) during hospitalization. Chest X-ray image depicted a ground-glass appearance from the mid to the lower right lung. The patient was diagnosed with right bronchopneumonia.\n\nThe intraoral lesions healed after a month of the treatment. The patient admitted that she has avoided foods containing gluten and routinely uses medicines provided by the Department of Oral Medicine. There were no adverse events or unwanted reactions from the drugs that she had been consumed. Follow-up therapy from the Department of Dermatology and Venereology includes methylprednisolone tablets (24 mg/day), cetirizine 10 mg tablets, and ranitidine 150 mg tablets. The patient was approved and written informed consent of this case including the images, and the institution has also approved for publication.", "summary": "A 74-year-old woman was referred to the Oral Medicine Department with a chief complaint of the blisters on the skin for a week and ulcers in the oral cavity appeared two days ago. Extraoral examination revealed crusts on the neck and extremities. The lips appeared dry and desquamative. Intraoral examination revealed erosive lesions covered with a white-yellowish plaques on the right and left sides of the buccal mucosa, an ulcer with a diameter of 0.5 cm, and purpura hemorrhagic on left buccal mucosa and right lateral border of the tongue. Histopathological examination of the skin lesion revealed a subepithelial blister with eosinophils and neutrophil cells. The definitive diagnosis of dermatitis herpetiformis was made. She was given 5 mg intravenous dexamethasone, cetirizine 10 mg, and clindamycin 300 mg by the dermatologist. We gave hyaluronic acid 0.025% mouthwash for oral ulcers and petroleum jelly for the lips. The oral lesions had significant improvement after 4 weeks of treatment. Two months later, the patient experienced acute exacerbation after being infected with COVID-19 (anti-SARS-CoV-2 IgG S-RBD >40,000 AU/mL). The oral lesions healed after a month of treatment.", "subclaim_evaluations": [ { "subclaim": "The patient is a 74-year-old woman.", "support_label": "supported" }, { "subclaim": "She was referred to the Oral Medicine Department.", "support_label": "supported" }, { "subclaim": "Her chief complaint was blisters on the skin for a week.", "support_label": "supported" }, { "subclaim": "Oral ulcers appeared two days before the visit.", "support_label": "supported" }, { "subclaim": "Extraoral examination revealed crusts on the neck and extremities.", "support_label": "supported" }, { "subclaim": "The lips appeared dry and desquamative.", "support_label": "supported" }, { "subclaim": "Intraoral examination showed erosive lesions covered with white-yellowish plaques on the buccal mucosa.", "support_label": "supported" }, { "subclaim": "An ulcer with a diameter of 0.5 cm was found.", "support_label": "supported" }, { "subclaim": "Purpura hemorrhagic was observed on the left buccal mucosa.", "support_label": "supported" }, { "subclaim": "Histopathological examination showed a subepithelial blister.", "support_label": "supported" }, { "subclaim": "The definitive diagnosis was dermatitis herpetiformis.", "support_label": "supported" }, { "subclaim": "She received 5 mg intravenous dexamethasone.", "support_label": "supported" }, { "subclaim": "She was given cetirizine 10 mg.", "support_label": "supported" }, { "subclaim": "She was given clindamycin 300 mg.", "support_label": "supported" }, { "subclaim": "Hyaluronic acid 0.025% mouthwash was prescribed for oral ulcers.", "support_label": "supported" }, { "subclaim": "Petroleum jelly was given for the lips.", "support_label": "supported" }, { "subclaim": "The oral lesions showed significant improvement after 4 weeks of treatment.", "support_label": "not_supported" }, { "subclaim": "Two months later, the patient experienced an acute exacerbation.", "support_label": "supported" }, { "subclaim": "The exacerbation occurred after infection with COVID-19.", "support_label": "supported" }, { "subclaim": "The anti-SARS-CoV-2 IgG S-RBD level was >40,000 AU/mL.", "support_label": "supported" }, { "subclaim": "The oral lesions healed after a month of treatment.", "support_label": "supported" } ] }, { "id": "multiclinsum_test_1030_en.txt", "fulltext": "A 42-year-old man, previously healthy, was living with his step father and other members of an extended family in a small farm. He presented with a first episode of a motor seizure that started on the left side of his body before becoming generalized. Shortly afterwards, he noticed left hemiparesis and dysarthria; he was admitted to our institution through the emergency department.\nAfter a physical examination, magnetic resonance imaging (MRI) of the patient revealed a well-defined, spherical lesion, located in the superior aspect of the anterior limb of the internal capsule and right striatum, with surrounding edema . Laboratory studies found no systemic compromise and no underlying immunocompromise. We decided to excise and analyze the aforementioned lesion. Performing an image-guided frontal craniotomy, using the Leksell Stereotactic G-Frame (Elekta Instruments AB, Stockholm, Sweden), we planned the trajectory to avoid the head of the caudate nucleus, the genu of the internal capsule, the putamen, and other critical structures. The mass was completely excised and the thalamostriate vein, which was adhered to the mass, was preserved. Craniotomy was performed, instead of a stereotactic biopsy, because we suspected the lesion to be a high-grade glioma that was accessible to surgical resection.\nIn the pathological analysis, there was an evident atypical T and B infiltrate; morphological and phenotypical characteristics of Grade 1 lymphomatoid granulomatosis. The patient was subjected to thoracic and abdominal screening, which revealed paratracheal, jugular, and inguinal adenopathies, but no other masses.\nAfter consulting with the hematology group, the patient received a four-cycle medical treatment with rituximab and prednisone. Clinically, he recovered almost completely with strength of 4/5 and complete reintegration to his daily activities, which involved bimanual work. Six months after his diagnosis, a new MRI showed the absence of new or residual lesions.\nTwo years after the surgery the patient continued to be free of seizures, and his MRI showed no evidence of new lesions, areas of restriction of diffusion, or anomalous enhancements that could indicate residual or recurrent tumor .", "summary": "A 42-year-old male presented with motor seizures and loss of consciousness for 10 minutes along with dysarthria and left hemiplegia. Neurological examination and imaging with magnetic resonance imaging (MRI) of the brain revealed a mass in the right striatum. The patient was hospitalized and underwent an image-guided right frontal craniotomy using the Leksell Stereotactic G-Frame. Pathology reported a lymphomatoid granulomatosis. Being immunocompetent, the patient received medical treatment with prednisone and rituximab. Two years after his diagnosis, the patient had no active disease and his brain MRI did not show contrast enhancement. After almost 3 years of follow-up, the patient has a mild weakness in the left-side of his body (4/5), is seizure-free, and can walk and perform daily activities.", "subclaim_evaluations": [ { "subclaim": "The patient is a 42-year-old male.", "support_label": "supported" }, { "subclaim": "The patient had motor seizures.", "support_label": "supported" }, { "subclaim": "The patient lost consciousness for 10 minutes.", "support_label": "not_supported" }, { "subclaim": "The patient had dysarthria.", "support_label": "supported" }, { "subclaim": "The patient had left hemiplegia.", "support_label": "not_supported" }, { "subclaim": "MRI of the brain showed a mass in the right striatum.", "support_label": "supported" }, { "subclaim": "The patient underwent an image-guided right frontal craniotomy.", "support_label": "supported" }, { "subclaim": "The Leksell Stereotactic G-Frame was used during the craniotomy.", "support_label": "supported" }, { "subclaim": "Pathology reported lymphomatoid granulomatosis.", "support_label": "supported" }, { "subclaim": "The patient was immunocompetent.", "support_label": "supported" }, { "subclaim": "The patient received prednisone.", "support_label": "supported" }, { "subclaim": "The patient received rituximab.", "support_label": "supported" }, { "subclaim": "Two years after diagnosis, the patient had no active disease.", "support_label": "supported" }, { "subclaim": "Two years after diagnosis, brain MRI did not show contrast enhancement.", "support_label": "supported" }, { "subclaim": "After almost 3 years of follow-up, the patient has mild left-side weakness (4/5).", "support_label": "not_supported" }, { "subclaim": "After almost 3 years of follow-up, the patient is seizure-free.", "support_label": "not_supported" }, { "subclaim": "After almost 3 years of follow-up, the patient can walk.", "support_label": "not_supported" } ] }, { "id": "multiclinsum_test_2962_en.txt", "fulltext": "A 52-year-old female was referred to our ophthalmology clinic with decreased vision and increased tearing.\nShe was diagnosed with stage III Alport syndrome two years prior which was currently stable per her nephrologist. During these two years had gradual decline in her visual acuity that was not correctable to 20/20.\nShe had a past medical history of asthma, diabetes mellitus, and hypertension.\nFamily history was positive for Alport syndrome in her mother and brother but without any known ocular or hearing abnormalities.\nOn initial examination , uncorrected distance visual acuity was 20/60 on the right and 20/30 on the left, with a corrected visual acuity of 20/30 bilaterally.\nSlit lamp examination showed bilateral eyelid laxity, papillary conjunctival changes, prominent nerves, superficial punctate keratitis, unilateral (OD) anterior basement membrane changes, with no guttata, apical scarring, or corneal striae. Dilated fundus exam revealed bilateral floaters in the vitreous humor and normal retinal vasculature.\nInitial Pentacam (Oculus, Wetzlar, Germany) tomography revealed mean keratometry of 47.9 D in the right and 48.3 D in the left, with a 2 mo follow-up scan revealing a mean keratometry of 48.1 D and 48.5 D respectively . During this 2 mo period progressive corneal thinning occurred bilaterally. There was also bilateral anterior curvature steepening with no appreciable changes in the posterior curvature.", "summary": "A 52-year-old female was referred to our ophthalmology clinic with decreased vision and increased tearing. She was diagnosed with stage III Alport syndrome two years prior. Upon examination she was found to have average keratometries of 48 D bilaterally with tomographic evidence of keratoconus.", "subclaim_evaluations": [ { "subclaim": "The patient is a 52-year-old female.", "support_label": "supported" }, { "subclaim": "The patient was referred to an ophthalmology clinic.", "support_label": "supported" }, { "subclaim": "The patient reported decreased vision.", "support_label": "supported" }, { "subclaim": "The patient reported increased tearing.", "support_label": "supported" }, { "subclaim": "The patient was diagnosed with stage III Alport syndrome two years prior.", "support_label": "supported" }, { "subclaim": "The patient had average keratometries of 48 D bilaterally.", "support_label": "supported" }, { "subclaim": "Tomographic evidence showed keratoconus.", "support_label": "supported" } ] }, { "id": "multiclinsum_test_2098_en.txt", "fulltext": "In May 2018, a 43-year-old Chinese man was admitted to our hospital with lumbago and inguinal lymph node enlargement. Figure summarizes the important events of this patient according to the timeline. The blood routine examination showed an increase in lactate dehydrogenase (LDH; 887 U/L) and a decrease in hemoglobin (Hb; 105 g/L). PET/CT showed multiple lymph nodes enlargements, including a large abdominal mass which was 13.9 × 10.6 cm in size, together with multiple bone lesions. The biopsy of cervical lymph node demonstrated that the lymph node structure was destroyed completely, which was mainly composed of small to medium-sized lymphocytes with round or slightly irregular nucleus, deeply stained chromatin, inconspicuous nucleoli, scant pale cytoplasm and rare apoptosis . Also, significant hyperplasia of large cells with centroblastic and immunoblastic morphology was seen in the focal areas, with large and round nucleus, condensed chromatin, one or more small nucleoli . Immunohistochemical (IHC) staining demonstrated the cells were positive for CD20 , CD19, CD10, BCL6 , BCL2 and negative for TdT , C-MYC, Cyclin D1, SOX11, CD23, LEF1, CD21, CD43, CD3, CD5 and EBER. Ki-67 was 10% in small cell areas and 40% in large cell areas. Fluorescence in situ hybridization (FISH) showed the cells were positive for BCL2::IGH fusion , without translocation of MYC or BCL6 . Also, the biopsy of bone marrow was performed, and we observed the hyperplasia was extremely active with almost no adipose tissue, and the central mother large cells presented a diffuse growth pattern. The IHC result demonstrated that the cells were positive for CD19, CD20, CD79a, CD10, MUM1, Ki-67, BCL6, C-MYC and BCL2, while negative for CD3 and TdT. Thus, this patient was diagnosed with low grade FL (account for 80%) combined with DLBCL (20%) at a stage of IVB, and given R-CHOP regimen (rituximab, cyclophosphamide, doxorubicin, vindesine, prednisone). After 1 cycle of R-CHOP treatment, lumbago was significantly relieved and the treatment regimen was changed to HD-MTX (high dose methotrexate) combined with 80% dose R-EPOCH (rituximab, cyclophosphamide, doxorubicin, vindesine) due to the high IPI (international prognostic index) score of 4. The abdominal mass reduced to 7.5 × 3.5 and this patient achieved partial remission (PR) following 1 cycle of HD-MTX/R-EPOCH treatment. In the following 5 cycles of HD-MTX/R-EPOCH treatment, the abdominal mass was treated with additional 30 Gy radiotherapy. However, multiple masses in the abdominal cavity, many nodules around both kidneys and the right adrenal gland, were found after 6 cycles of the treatment, together with the increased glucose metabolism. Thus, he achieved progression disease (PD).\nIn Jan. 2019, a fine needle aspiration biopsy of the abdominal mass was taken. The biopsy demonstrated that the tumor cells presented with diffuse growth pattern, mainly composed of uniformly medium-sized blastoid cells with round or slightly irregular nuclei, dispersed chromatin, unclear nucleoli and scant bluish-grey cytoplasm . The cells were negative for CD20 , BCL6 and CD3 staining, while positive for TdT (Fg. I), PAX5, CD38, CD10, BCL2, C-MYC and MUM1 staining. Ki-67 was about 60%. FISH revealed fusions of BCL2::IGH and translocation of MYC , without BCL6 translocation . According to the 5th WHO classification, a diagnosis of TdT positive HGBL with MYC and BCL2 rearrangements (“double hit”) transformed from FL/DLBCL was made after 8 months of FL/DLBCL confirmation. Then, chidamide and pembrolizumab were given and the disease was mitigated, but he discontinued chemotherapy for 3 months due to the COVID-19 pandemic, and the disease progressed. The biopsy of the abdominal neoplasm was taken once again in Apr. 2020, and the diagnosis of TdT positive “double hit” HGBL remained valid. This patient died in Jul. 2021, with an OS time of 37.8 months.\nTo further understand the pathogenesis of TdT positive “double hit” HGBL after the treatment of FL/DLBCL, the targeted sequencing of 571 lymphoma-related genes (Supplementary Table 1) were carried out on Nova-seq (Illumina, San Diego, CA, USA). Variants, including SNVs (single nucleotide variations) and Indels (Insertion and deletion) were screened by Shanghai Rightongene Biotechnology Co., Ltd. (Shanghai, China) based on the following filter conditions: (1) SNVs or Indels with a mutation allele frequency (MAF) ≥ 0.001 in databases of 1000 genomes project , 1000 genome East Asian, ExAC all or ExAC East Asian and gnomAD were removed; (2) SNVs or Indels with a variant allele frequency (VAF) ≥ 5% was retained; (3) SNVs or Indels including stopgain, stoploss, frameshift, non-frameshift and splicing sites were retained; and (4) Missense mutations with sift ≤ 0.05, Polyphen2_HVAR_pred ≥ 0.447 and CADD > 4 were retained. KMT2D, FOXO1, CREBBP, ATM, STAT6, BCL7A, DDX3X, MUC4, FGFR3, ARID5B, DDX11 and PRKCSH were the co-mutations detected in both the primary and transformed tissues, while mutations in CCND3, BIRC6, ROBO1 and CHEK2 genes emerged when transformed into HGBL .", "summary": "This is a 43-year-old Chinese man who was diagnosed with low grade FL (account for 80%) combined with DLBCL (20%) at a stage of IVB. The patient presented with BCL2/IGH translocation without MYC rearrangement, as well as the expressions of CD20, CD19, CD10 and BCL2 at the initial diagnosis of FL/DLBCL. MYC rearrangement and TdT expression occurred after the treatment. The targeted sequencing revealed mutations in KMT2D, FOXO1, CREBBP, ATM, STAT6, BCL7A, DDX3X, MUC4, FGFR3, ARID5B, DDX11 and PRKCSH genes were the co-mutations shared by the FL/DLBCL and TdT positive \"double hit\" HGBL, while CCND3, BIRC6, ROBO1 and CHEK2 mutations specifically occurred after the treatment. The overall survival time was 37.8 and 17.8 months after the initial diagnosis of FL/DLBCL and TdT positive \"double hit\" HGBL, respectively.", "subclaim_evaluations": [ { "subclaim": "The patient is a 43-year-old Chinese man.", "support_label": "supported" }, { "subclaim": "The patient was diagnosed with low grade FL.", "support_label": "supported" }, { "subclaim": "The FL accounts for 80% of the tumor.", "support_label": "supported" }, { "subclaim": "The patient was diagnosed with DLBCL.", "support_label": "supported" }, { "subclaim": "The DLBCL accounts for 20% of the tumor.", "support_label": "supported" }, { "subclaim": "The stage at diagnosis was IVB.", "support_label": "supported" }, { "subclaim": "The patient had BCL2/IGH translocation.", "support_label": "supported" }, { "subclaim": "The patient had no MYC rearrangement at initial diagnosis.", "support_label": "not_supported" }, { "subclaim": "The patient had CD20 expression at initial diagnosis.", "support_label": "supported" }, { "subclaim": "The patient had CD19 expression at initial diagnosis.", "support_label": "supported" }, { "subclaim": "The patient had CD10 expression at initial diagnosis.", "support_label": "supported" }, { "subclaim": "The patient had BCL2 expression at initial diagnosis.", "support_label": "supported" }, { "subclaim": "MYC rearrangement occurred after treatment.", "support_label": "supported" }, { "subclaim": "TdT expression occurred after treatment.", "support_label": "supported" }, { "subclaim": "Targeted sequencing revealed mutations in KMT2D.", "support_label": "supported" }, { "subclaim": "Targeted sequencing revealed mutations in FOXO1.", "support_label": "supported" }, { "subclaim": "Targeted sequencing revealed mutations in CREBBP.", "support_label": "supported" }, { "subclaim": "Targeted sequencing revealed mutations in ATM.", "support_label": "supported" }, { "subclaim": "Targeted sequencing revealed mutations in STAT6.", "support_label": "supported" }, { "subclaim": "Targeted sequencing revealed mutations in BCL7A.", "support_label": "supported" }, { "subclaim": "Targeted sequencing revealed mutations in DDX3X.", "support_label": "supported" }, { "subclaim": "Targeted sequencing revealed mutations in MUC4.", "support_label": "supported" }, { "subclaim": "Targeted sequencing revealed mutations in FGFR3.", "support_label": "supported" }, { "subclaim": "Targeted sequencing revealed mutations in ARID5B.", "support_label": "supported" }, { "subclaim": "Targeted sequencing revealed mutations in DDX11.", "support_label": "supported" }, { "subclaim": "Targeted sequencing revealed mutations in PRKCSH.", "support_label": "supported" }, { "subclaim": "The mutations in KMT2D, FOXO1, CREBBP, ATM, STAT6, BCL7A, DDX3X, MUC4, FGFR3, ARID5B, DDX11, and PRKCSH were shared by FL/DLBCL and TdT positive 'double hit' HGBL.", "support_label": "supported" }, { "subclaim": "CCND3 mutations specifically occurred after treatment.", "support_label": "supported" }, { "subclaim": "BIRC6 mutations specifically occurred after treatment.", "support_label": "supported" }, { "subclaim": "ROBO1 mutations specifically occurred after treatment.", "support_label": "supported" }, { "subclaim": "CHEK2 mutations specifically occurred after treatment.", "support_label": "supported" }, { "subclaim": "The overall survival time after the initial diagnosis of FL/DLBCL was 37.8 months.", "support_label": "supported" }, { "subclaim": "The overall survival time after the diagnosis of TdT positive 'double hit' HGBL was 17.8 months.", "support_label": "not_supported" } ] }, { "id": "multiclinsum_test_2135_en.txt", "fulltext": "A 69-year old female patient, with a previous history of hypertension, thyroidectomy due to hyperthyroidism and hysterectomy for uterus myomas, presented with a progressive swelling of the dorsal aspect of the right side of her neck without signs of vascular obstruction or venous stases. No abnormalities of neural status of the head and neck were observed. There was no functional or sensory loss of the right upper extremity. No signs of Horner's syndrome, dysphagia, cough or dyspnoe were evident. CT scan demonstrated a retroclavicular soft tissue tumour with a cranio-caudal extension of up to 4.5 cm which partially displaced the trachea to the left and compressed the subclavian vein. An adjacent tumour of dimensions 3.5 × 3.5 cm not clearly separated from the before mentioned tumour was located at the inferior right thyroid lobe, compressing the internal jugular vein. Near the confluence of these vessels a subtotal occlusion of the brachiocephalic vein is revealed . The MRI scan added no further information on the origin of the tumour or the cause of venous occlusion. There were no clear signs of tumour infiltration of the brachial plexus, brachial artery, esophagus or trachea. The preoperative chest x-ray displayed a right sided upper mediastinal enlargement . Additional venous angiography indicated a filiform stenosis of the subclavian vein. Within the brachicephalic vein a longitudinal, irregular partial displacement of the vascular lumen was depicted. Extensive blood flow in cervical and supraclavicular collateral vessels was present. Neither MRI, CT nor angiogram allowed for clear distinction of the intravascular process whether it was caused by intravascular tumour growth or thrombosis. Incisional biopsy one month prior to the oncological tumour resection revealed the histopathological diagnosis of a leiomyosarcoma.\nSurgical exposure was obtained via a triangular incision running from behind the right ear, along the anterior axillary line and across the sternum. First, the brachial plexus was dissected, the phrenic and recurrent nerves identified and followed distally. The upper border of the tumour became visible at the upper thoracic aperture. The recurrent nerve was observed to run through the tumour capsule. Further preparation was carried out from the distal edge of the wound. The pectoralis major muscle was elevated and care was taken to preserve the vascular pedicle (thoracoacromial A.V.). It was further observed that the first intercostal space was invaded by the tumour. Subsequently a thoracic wall resection including a partial resection of the right clavicle, the right half of the sternum and the costal attachment of the first three ribs was performed uncovering the mediastinum. The vena cava was revealed and trachea dissected. In this area the tumour was in close proximity to the trachea displacing it to the left but without tracheal infiltration. Next, the carotic artery and the jugular vein were exposed.\nThe tumour, located in the right supraclavicular region/upper mediastinum, was found to surround both the subclavian and the internal and external jugular vein. Hence a resection of the subclavian vein proximal to its conjunction with the superior vena cava was required. The internal as well as the external jugular vein were incorporated into the tumour conglomerate . The tumour was resected en bloc. A partial resection of the clavicle, partial resection of the sternum with removal of the brachiocephalic, sublcavian and right jugular vein and the recurrent nerve was necessary to obtain clear resection margins. The defect coverage was achieved by a pedicled myocutaneous pectoralis major island flap.\nWithin the surgical specimen multiple nodular polypoid tumour masses of soft consistence with diameters of up to 3.6 cm, immediately adjacent to vascular structures of the subclavian, internal jugular and brachiocephalic vein were present. The tumour with its intravascular and extravascular components comprised a total area of 7.6 × 8 × 3.3 cm. The largest intravascular tumour sprout extended close to the resection surface of the vessel.\nThe macroscopic appearance resembled an intravascular tumour originating from the subclavian vein with infiltration of extravascular structures.\nMicroscopically the spindle-shaped cells of this mesenchymal neoplasm originated from the media of the venous vessel wall . The tumour cells formed various fascicles interwoven with other longitudinal cross sectional neighbouring fascicles . The tumour cells were characterized by an eosinophilic cytoplasm and cigar shaped nuclei. The mitotic rate was 19/10 HPF (per high power field). Some foci of tumour necrosis were present.\nThe neoplasm derived from the media of the vessel wall, disrupted the existing vascular architecture and formed an intravascular tumour sprout.\nImmunohistochemically the majority of tumour cells were positive for smooth muscle actin and desmin. A positive reaction for the proliferation marker Ki 67 was found in 25% of all tumour cells,\nThus confirming the diagnosis of an intravascular leiomyosarcoma (malignancy grading GII)\nPostoperatively only mild signs of mixed venous and lymphatic stases of the upper extremity following the resection of the subclavian vein were observed due to the well established collateral blood flow (as seen in the preoperative angiogram). These symptoms could be positively influenced by elastic compression dressings and physical lymph drainage. Owing to the resection of the right recurrent nerve, right sided vocal cord palsy occurred. Logopaedic training was initiated. The patient recovered well and was discharged two weeks later. Both pre- and post-operatively no symptoms of pulmonary embolism were detected.\nUnfortunately the patient declined the recommended radiation therapy.\nAfter an initial 5 month of tumour free survival without evident signs of either local or systemic metastasis a tumour relapse was detected. At this stage the patient refused further treatment apart from a palliative chemotherapy.", "summary": "A 69-year old patient presented with a biopsy proven leiomyosarcoma of the right supraclavicular region. Tumour resection and histological assessment verified the intravascular tumour origin arising from the internal jugular vein and extending into the surrounding soft tissue.", "subclaim_evaluations": [ { "subclaim": "The patient is 69 years old.", "support_label": "supported" }, { "subclaim": "The patient has a biopsy-proven leiomyosarcoma.", "support_label": "supported" }, { "subclaim": "The leiomyosarcoma is located in the right supraclavicular region.", "support_label": "supported" }, { "subclaim": "Tumour resection was performed.", "support_label": "supported" }, { "subclaim": "Histological assessment was conducted.", "support_label": "supported" }, { "subclaim": "The tumour originated from the internal jugular vein.", "support_label": "not_supported" }, { "subclaim": "The tumour extended into the surrounding soft tissue.", "support_label": "supported" } ] }, { "id": "multiclinsum_test_1511_en.txt", "fulltext": "A 39-year-old woman was admitted to our hospital for a laparoscopy-assisted vaginal hysterectomy under general anaesthesia (induced with midazolam, fentanyl and propofol, and maintained with sevoflurane in oxygen/air mixture). The patient reported an unremarkable medical and family history and stated that she had never smoked. She also denied the following: (a) regular exposure to environmental tobacco smoke (at home or at her workplace), (b) abuse of illicit or recreational drugs, (c) food or medication allergies, (d) recent camping or wild animal contact. A more detailed history revealed that the patient was otherwise healthy and had taken no medications prior to the present illness. Three days after her surgery (with prophylactic ampicillin/sulbactam administered as i.v. bolus), the patient experienced acute epigastric pain with vomiting and diarrhoea along with dyspnea that gradually increased in severity. The patient had a temperature of 38.2°C, blood pressure of 90/60 mmHg, hearth rate of 120 beats/min, and respiratory frequency of 30 breaths/min. Inspection of her thorax revealed decreased movement of the chest wall, a hyperresonant percussion note, diminished fremitus and reduced breath sounds on the right side. The abdominal examination showed distension, guarding, and diffuse tenderness. The patient’s physical signs and radiographic findings were compatible with peritonitis and pneumothorax; the laboratory examination revealed a leukocyte count of 2,100 cells/μL, with 84% neutrophils and 3% eosinophils. A laparotomy revealed purulent fluid throughout the abdominal cavity, which was associated with fibrinous plaques covering most of the abdominal viscera; these findings were the result of a rectal perforation. A perforation closure was performed and peritoneal toilets (a 9-day-toilet plan) were initiated. The pneumothorax was managed with a thoracostomy tube drainage. The patient was admitted to the intensive care unit (ICU) and began an empirical treatment with piperacillin and tazobactam. On the day of admission, an arterial blood analysis yielded PaO2 of 67 mmHg and SaO2 of 91.2% on ambient air. Non-invasive ventilation was started under moderate sedation with propofol. In the meantime, Enterococcus and Escherichia coli were cultured from the peritoneal exudate. On the seventh postoperative day, the patient’s clinical condition worsened, with increasing intra-abdominal fibrinous adhesions and paralytic ileus; the previous treatment was discontinued and an empirical administration of imipenem was begun on the conjecture of possible resistant enterococci. On the tenth postoperative day, she developed a new spontaneous pneumothorax on the right side , with respiratory rate increased to 28 breaths/min; the pathological event was managed with a thoracostomy tube drainage. Because the patient’s clinical condition were worsened, imipenem was discontinued on the twelfth day and substituted with tigecycline based on the antibiotic-sensitivity results for Enterococcus faecium isolated from the peritoneal toilet on the tenth postoperative day. On the eighteenth postoperative day, the patient’s respiratory distress increased (34 breaths/min and SaO2 of 88% with 6 L/min supplemental oxygen), her temperature was 37.6°C, her hearth rate 110 beats/min and her leukocyte count 19,400 cells/μL (neutrophils 86%; eosinophils 2%). Computed tomography (CT) of the chest revealed an abundant left-sided pleural effusion pressing on the lower pulmonary lobe, and multiple areas of alveolar infiltrates in the upper and middle right pulmonary lobes. The serology (hepatitis B virus, hepatitis C virus, human immunodeficiency virus, Cytomegalovirus, Chlamydia and Mycoplasma) eventually proved negative. Antinuclear antibody, anti-neutrophil cytoplasmatic antibody and rheumatoid factors were negative or non-specific. The levels of immunoglobulin [Ig] G, IgA, IgM, complement C3 and C4 were within the normal limits, and the IgE concentration was 112 kU/L. The CD4+/CD8+ T lymphocytes ratio was 1.7; since this value is usually significantly decreased in patients with various types of respiratory viral infections, the presence of influenza virus and/or bocavirus was not investigated.\nThe blood cultures for aerobic and anaerobic bacteria remained sterile. No pneumocystis was detected by polymerase chain reaction. The patient was then empirically treated withceftazidime and clarithromycin for atypical pneumonia, on the basis on the radiographic findings. Despite these measures, she did not improve and continued to have fever, with a temperature of approximately 37.5°C and mild leukocytosis. On the twenty-fifth postoperative day, a chest CT scan demonstrated a left-sided pneumothorax with dense consolidations of the left upper and middle pulmonary lobes along with multiple areas of alveolar infiltrates in the upper and middle right pulmonary lobes. As the patient gradually became more dyspneic and hypoxic, she was placed under ventilation with continuous positive airway pressure. Instead of previous antibiotics, rifampicin and moxifloxacin were administered because of a positive test for Legionella, which, however, was refuted by laboratory on the following day. Because the patient’s respiratory failure further worsened, the previous treatment was discontinued and empirically substituted with three broad-spectrum antibiotics (linezolid, meropenem and moxifloxacin). Eosinophilic pneumonia was suspected when she showed no response to antibiotics within the next 2 days. Bronchoscopy demonstrated inflamed mucosa in both upper lungs with thick secretions in both lower lungs, and many nucleated cells (including 56% eosinophils) were detected in BAL fluid. These findings unequivocally supported a diagnosis of AEP, and parenteral methylprednisolone was initiated. Significant recovery occurred within the next 24 h, so the antibiotics were discontinued. The clinical symptoms further subsided and the patient was successfully extubated within 2 days after the initiation of steroids. The laboratory data and chest radiology revealed marked improvement. After 20 days in the surgery department, the patient was discharged with a course of oral prednisone that was tapered for 14 days. At 1 year following surgery, the patient did not have any recurrence of her pulmonary symptoms or infiltrates.", "summary": "A 39-year-old German woman was admitted to our hospital for a laparoscopy-assisted vaginal hysterectomy under general anaesthesia. The surgical intervention was followed by peritonitis in the early postoperative course. Following anaesthesia induction with propofol/midazolam and during the prolonged therapy with several broad-spectrum antibiotics, she developed AEP and three spontaneous (one left-sided and two right-sided) pneumothoraces, the latter ones observed in quick succession. Symptoms, laboratory markers, and chest radiology significantly improved after a one-day treatment with methylprednisolone.", "subclaim_evaluations": [ { "subclaim": "The patient is a 39-year-old German woman.", "support_label": "not_supported" }, { "subclaim": "She was admitted for a laparoscopy-assisted vaginal hysterectomy.", "support_label": "supported" }, { "subclaim": "The procedure was performed under general anaesthesia.", "support_label": "supported" }, { "subclaim": "She developed peritonitis in the early postoperative course.", "support_label": "supported" }, { "subclaim": "Anaesthesia was induced with propofol and midazolam.", "support_label": "supported" }, { "subclaim": "She received prolonged therapy with several broad-spectrum antibiotics.", "support_label": "supported" }, { "subclaim": "She developed AEP.", "support_label": "supported" }, { "subclaim": "She had three spontaneous pneumothoraces.", "support_label": "supported" }, { "subclaim": "One pneumothorax was left-sided.", "support_label": "not_supported" }, { "subclaim": "Two pneumothoraces were right-sided.", "support_label": "supported" }, { "subclaim": "The right-sided pneumothoraces occurred in quick succession.", "support_label": "supported" }, { "subclaim": "She was treated with methylprednisolone for one day.", "support_label": "supported" }, { "subclaim": "Symptoms improved after one day of methylprednisolone treatment.", "support_label": "supported" }, { "subclaim": "Laboratory markers improved after one day of methylprednisolone treatment.", "support_label": "supported" }, { "subclaim": "Chest radiology improved after one day of methylprednisolone treatment.", "support_label": "supported" } ] }, { "id": "multiclinsum_test_2596_en.txt", "fulltext": "A 67 years-old Tujia nationality man was admitted to our institution in June 2022 with a history of dysphagia, slight chest pain when obstruction, and dyspnea when climbing stairs or going uphill. Gastroscope showed that a new organism which was 29 to 35 cm away from the esophagus could be seen protruding from the lumen, with rigid wall, central ulceration, covered with filthy moss, brittle texture, and easy to bleed when touched. Then he was diagnosed with esophageal squamous cell carcinoma by endoscopic biopsy. On June 14th, echocardiography revealed the presence of an intracardiac mass inside the right ventricle . The echocardiography showed there is a slight increase in echogenicity in the right ventricle, and considering the possibility of an embolus based on medical history, a space occupying lesion needs to be excluded, further examination is recommended; widening of the aortic sinus and ascending part; mild symmetrical thickening of the left ventricular wall; mitral valve, tricuspid valve, aortic valve, pulmonary valve local regurgitation; left ventricular diastolic dysfunction. Then thoracic computed tomography was requested for a better assessment about the mass intracardiac . The thoracic computed tomography results were as follows: Space occupying lesions in the middle and lower thoracic segments of the esophagus. Considering the possibility of esophageal cancer, multiple lymph nodes in the mediastinum are shown, follow-up is recommended. There are scattered solid and sub-solid nodules in both lungs, and metastatic tumors need to be excluded. It is recommended to follow up closely. Double emphysema; there is a little chronic inflammation in the medial segment of the middle lobe of the right lung, the lower lingual segment of the upper lobe of the left lung, and the lower lobe of both lungs. Right ventricular filling defect shadow, considering thrombosis, reexamination is recommended.\nOverall, the mass was suspected to be tumor or embolus. Hypersensitive D dimer is 543 ng/mL and Color Doppler ultrasound of blood vessels in extremities showed no thrombus. We chose to treat esophageal cancer first after multi-department consultation and communication with the patient family. On June 17th, 2022, single drug chemotherapy of pabolizumab 200 mg + albumin paclitaxel 400 mg was performed successfully. After treatment, swallowing obstruction and chest pain slightly improved but the patient developed skin itching and rash.\nOn June 21st, Review color ultrasound showed a right intraventricular mass (48 × 17 mm) , the boundary is clear, the shape is regular, and the base is wide. It swings with the heart beating. Part of the echo located in the outflow tract of the right ventricle, and part of the outflow tract is about 10.3 mm wide. After the consultation of cardiac surgery in our hospital, the patient underwent cardiac tumor resection and intraoperative frozen biopsy on June 27, 2022. The surgical process is as follows: after successful tracheal intubation under general anesthesia, the patient is placed in a flat position, with a jugular vein catheter, a radial artery catheter, and a urinary catheter. After routine iodine disinfection, the patient is covered with a cloth. The sternum is incised in the middle of the sternum, and the skin is cut subcutaneously. The sternum is longitudinally sawn, bone wax is used to stop bleeding, the sternum is opened, and a pericardium is cut. The patient is suspended, and the ascending aorta is intubated, the superior and inferior vena cava is intubated, and the left atrium is intubated. Extracorporeal circulation is established routinely. After cardiac arrest, cut open the right atrium and conduct intracardiac exploration: The tumor is located on the anterior wall of the right ventricle, widely distributed from the apex to the distal end of the right ventricular outflow tract. The surface of the tumor is uneven, crispy, and the base is wide. The pulmonary artery trunk is blocked, and the tumor is gradually removed. A small amount of tumor tissue is taken and sent for intraoperative frozen pathological examination. The heart cavity is repeatedly rinsed with ice and saline, and the pulmonary artery blocking forceps are removed. No tumor tissue is found in the pulmonary artery during exploration. The intraoperative frozen pathological report is “metastatic malignant tumor.” The tricuspid valve was well closed during the right ventricular injection test, and the right atrial incision was sutured. After rewarming, the ascending aorta was opened. The heart was defibrillated once and the cardiopulmonary bypass was paralleled, gradually stopping the extracorporeal circulation. After removing the extracorporeal circulation, a temporary cardiac pacing lead was placed on the surface of the right ventricle, and a pericardial mediastinal drainage tube was placed to completely stop bleeding. After counting the number of pairs, the chest closure surgery was completed layer by layer. Return to the CCU ward safely.\nPathological examination (frozen section) on June 27, 2022 was reported: Cardiac space-occupying, malignant tumor with massive necrosis, consistent with the metastasis of poorly differentiated squamous cell carcinoma, it is recommended to examine the esophagus. Immunohistochemistry: 35BH11 (−), CK (+++), P63 (+++). KI-67 35% (+), P40 (+++) . Besides that, the reason the mass has been considered as an esophagus metastasis is that intracardiac lesions from esophagus cancer are described in the literature.[\nThe second and third cycles of anti-tumor treatment were performed on August 4, 2022 and August 30, 2022. Review SD (stable disease). From September 26, 2022 to November 10, 2022, he was given palliative chest radiotherapy, prescription dose: PGTVnd: 69.0 Gy/30f. PCTV: 51.0 Gy/30f, PGTV: 60.0 Gy/30f. The patient maintained a stable weight during radiotherapy . By the computed tomography and enhanced CT, it can be seen that the treatment in the 3 months has significantly improved the patient condition .\nIt is pity that, due to the outbreak of COVID-19, the patient eventually suffered from severe pulmonary infection on Dec 19th. The infection rapidly progressed and worsened under the influence of various inflammatory factors. And the patient was died of the acute respiratory distress syndrome 2 weeks later.", "summary": "We reported a case of a 67 years-old man diagnosed as right ventricular metastasis from esophageal squamous cell with the help of echocardiography and pathological biopsy. Moreover, the patient survival period reached an astonishing 6 months, which far exceeded 4 weeks reported in previous literature.", "subclaim_evaluations": [ { "subclaim": "The patient was a 67-year-old man.", "support_label": "supported" }, { "subclaim": "The patient was diagnosed with right ventricular metastasis.", "support_label": "supported" }, { "subclaim": "The primary tumor was esophageal squamous cell carcinoma.", "support_label": "supported" }, { "subclaim": "Echocardiography was used in the diagnosis.", "support_label": "supported" }, { "subclaim": "A pathological biopsy was performed.", "support_label": "supported" }, { "subclaim": "The patient's survival period was 6 months.", "support_label": "not_supported" }, { "subclaim": "Previous literature reported a survival period of 4 weeks.", "support_label": "not_supported" } ] }, { "id": "multiclinsum_test_1676_en.txt", "fulltext": "A 52-year-old female presented to our hospital with blurred vision in her left eye for approximately 1 wk.\nThe patient reported no headache or eye pain. She had no other diseases.\nUnremarkable.\nNo abnormalities were found on slit lamp examination.\nThe patient underwent a comprehensive ophthalmic examination, including decimal best corrected visual acuity, color fundus photography, spectral domain optical coherence tomography (OCT) and fluorescein fundus angiography. On first examination, her best corrected visual acuity was 20/40 in the left eye and 20/20 in the right eye. Anterior segment and intraocular pressure findings were normal in both eyes. Fundus photography of the left eye showed a seemingly normal adult oculus fundus without any obvious hard exudate or hemorrhage . OCT demonstrated a hypo-reflective space beneath both the neurosensory retina and the pigment epithelium layer . The late phase of fluorescein angiography revealed hyper fluorescence . On the basis of these findings, a diagnosis of CSC was made. As the patient lived thousands of miles from Shanghai and did not perceive obvious changes in her eyes, she declined follow-up visits to the hospital.\nOne month later, her visual acuity deteriorated suddenly. On examination, her best corrected visual acuity in the left eye was 20/100. A sub-retinal hemorrhage, hard exudate and reddish-orange nodules were found on fundus photography . OCT demonstrated a pigment epithelium detachment and sub-retinal fluid . The late phase of fluorescein angiography revealed increased hyper-fluorescence compared to that observed one year previously . These characteristics led to the diagnosis of PCV.", "summary": "A 52-year-old woman presented to our hospital with blurred vision in her left eye for approximately 1 wk. Anterior segment and intraocular pressure findings were normal in both eyes. Fundus photography of the left eye showed a seemingly normal adult oculus fundus without any obvious hard exudate or hemorrhage. Optical coherence tomography exhibited a hypo-reflective space beneath both the neurosensory retina and the pigment epithelium layer. The late phase of fluorescein angiography revealed increased leakage. The patient was initially diagnosed with CSC. At follow-up, however, the final diagnosis turned out to be PCV.", "subclaim_evaluations": [ { "subclaim": "The patient is a 52-year-old woman.", "support_label": "supported" }, { "subclaim": "She presented with blurred vision in her left eye.", "support_label": "supported" }, { "subclaim": "The blurred vision had been present for approximately 1 week.", "support_label": "supported" }, { "subclaim": "Anterior segment findings were normal in both eyes.", "support_label": "supported" }, { "subclaim": "Intraocular pressure findings were normal in both eyes.", "support_label": "supported" }, { "subclaim": "Fundus photography of the left eye showed a seemingly normal adult oculus fundus.", "support_label": "supported" }, { "subclaim": "Fundus photography showed no obvious hard exudate.", "support_label": "supported" }, { "subclaim": "Fundus photography showed no obvious hemorrhage.", "support_label": "supported" }, { "subclaim": "Optical coherence tomography showed a hypo-reflective space beneath the neurosensory retina.", "support_label": "supported" }, { "subclaim": "Optical coherence tomography showed a hypo-reflective space beneath the pigment epithelium layer.", "support_label": "supported" }, { "subclaim": "The late phase of fluorescein angiography revealed increased leakage.", "support_label": "supported" }, { "subclaim": "The patient was initially diagnosed with central serous chorioretinopathy.", "support_label": "supported" }, { "subclaim": "The final diagnosis was polypoidal choroidal vasculopathy.", "support_label": "supported" } ] }, { "id": "multiclinsum_test_2054_en.txt", "fulltext": "A 44-year-old male presented with chronic osteomyelitis of the right tibia. The patient presented to the orthopaedic clinic due to right leg pain and swelling, the inability to bear weight, and multiple attacks of subjective fever. The right leg pain suddenly progressed over the prior 3 mo, without a history of recent trauma. The pain increased at night and later became constant even during rest. The pain was located mainly on the proximal right tibia with radiation to the right knee and middle third of the right leg. The patient also experienced multiple attacks of fever and night sweats.\nThe patient had an open fracture 22 years ago with an infection and was diagnosed with chronic osteomyelitis with a discharging sinus. The sinus had closed, but the pain continued. He was treated with evacuation of the abscess and courses of antibiotics.\nThe patient had a history of hypertension.\nNo personal or family history relevant to the presentation. No history of allergy to medications was reported.\nOn inspection, there was swelling of the right leg and skin redness on the anterior aspect of the proximal third of the right leg. We observed a skin scar with thin scar tissue over the tibia directly. There was no underlying soft tissue on the anterior aspect of the proximal right tibia with massive swelling and tenderness around this area. The patient had an intact neurovascular examination.\nLaboratory findings included slightly increased leukocytes (12.3 × 109/L; normal range: 4.5-11.0 × 109/L), haematocrit (40.2%; normal range: 41%-50%), platelets (522,000 mcL; normal range: 150,000 to 450,000 mcL), elevated erythrocyte sedimentation rate (95 mm/h, normal range: < 20 mm/h), and high C-reactive protein (133 mg/L; normal range: 0-10 mg/L). The patient had a discharging sinus on the anterior proximal third of the right leg in the centre of the previous scar. Culture from the sinus grew Staphylococcus aureus.\nAnteroposterior and lateral X-ray views showed multiple opacities, and magnetic resonance imaging showed a collection with high signal intensity in the proximal right tibia. The radiological studies revealed an intramedullary collection of the proximal right tibia with the impression of subacute osteomyelitis with multiple Brodie’s abscesses of the proximal right tibia .", "summary": "A 44-year-old male with a known case of hypertension, no history of allergies to medications, and a history of chronic osteomyelitis of the right tibia with discharging sinus over the anterolateral aspect of the leg. The pus culture grew Staphylococcus aureus, which was sensitive to clindamycin and vancomycin. The patient underwent irrigation and debridement with the placement of vancomycin cement beads made from 4 g of vancomycin powder and 40 g of polymethyl methacrylate. Three hours postoperatively, the patient developed a pruritic, erythematous, macular rash predominantly on his face, neck, chest, and lower extremities and to a lesser extent his upper extremities. A diagnosis of VFS was made and was successfully treated with cetirizine (10 mg, oral) and methylprednisolone sodium succinate (125 mg, intravenous). The patient continued to have itching with a facial rash for 12 h with gradual improvement. A decision was made to not remove the beads as the patient continued to improve. Gradually, the rash disappeared after 96 h with no further sequela.", "subclaim_evaluations": [ { "subclaim": "The patient is a 44-year-old male.", "support_label": "supported" }, { "subclaim": "The patient has a known case of hypertension.", "support_label": "supported" }, { "subclaim": "The patient has no history of allergies to medications.", "support_label": "supported" }, { "subclaim": "The patient has a history of chronic osteomyelitis of the right tibia.", "support_label": "supported" }, { "subclaim": "The patient has a discharging sinus over the anterolateral aspect of the leg.", "support_label": "supported" }, { "subclaim": "The pus culture grew Staphylococcus aureus.", "support_label": "supported" }, { "subclaim": "The Staphylococcus aureus isolate was sensitive to clindamycin.", "support_label": "not_supported" }, { "subclaim": "The Staphylococcus aureus isolate was sensitive to vancomycin.", "support_label": "not_supported" }, { "subclaim": "The patient underwent irrigation and debridement.", "support_label": "not_supported" }, { "subclaim": "Vancomycin cement beads were placed.", "support_label": "not_supported" }, { "subclaim": "The beads were made from 4 g of vancomycin powder.", "support_label": "not_supported" }, { "subclaim": "The beads were made from 40 g of polymethyl methacrylate.", "support_label": "not_supported" }, { "subclaim": "Three hours postoperatively, the patient developed a pruritic, erythematous, macular rash.", "support_label": "not_supported" }, { "subclaim": "The rash was predominantly on the face, neck, chest, and lower extremities.", "support_label": "not_supported" }, { "subclaim": "The rash was to a lesser extent on the upper extremities.", "support_label": "not_supported" }, { "subclaim": "A diagnosis of VFS was made.", "support_label": "not_supported" }, { "subclaim": "The patient was treated with cetirizine 10 mg, oral.", "support_label": "not_supported" }, { "subclaim": "The patient was treated with methylprednisolone sodium succinate 125 mg, intravenous.", "support_label": "not_supported" }, { "subclaim": "The patient continued to have itching with a facial rash for 12 hours.", "support_label": "not_supported" }, { "subclaim": "The rash gradually improved.", "support_label": "not_supported" }, { "subclaim": "The rash disappeared after 96 hours.", "support_label": "not_supported" }, { "subclaim": "The beads were not removed.", "support_label": "not_supported" } ] }, { "id": "multiclinsum_test_3327_en.txt", "fulltext": "Mr. RR, a 23-year-old male, presented at the emergency room reporting a week-long period of weakness that had worsened prior to admission, significantly impeding his daily activities. He described a four-month history of recurring, small fluid-filled sacs on the skin. These lesions evolved from reddish patches to rupturing and oozing, accompanied by itching but no pain or fever. He denied experiencing chest pain, shortness of breath, or vomiting but mentioned recent episodes of nausea. Upon examination, he appeared moderately unwell, with normal vital signs and pale conjunctiva. Physical assessment revealed palpable splenomegaly (Schuffner 6) but no lymph node enlargement or cardiac murmurs. Dermatologic examination revealed oedematous urticaria-like plaques, scaling, erosions, excoriations, and crusts all over the body, as well as a ruptured hemorrhagic bulla on the anterior body and left leg.\n\nComplete blood test showed that the White Blood Cell Count (WBC) was 23 × 109/l, the Absolute Neutrophil Count (ANC) was 644 cells/μl, the Hemoglobin (Hb) was 99 g/, and the Platelet Count (Plt) was 28 × 109/l. Bone marrow aspiration consistent with acute lymphoblastic leukemia-L1, led to the diagnosis of acute lymphoblastic leukemia in the patient. The decision for chemotherapy has not been approved by the patient, so patient only received corticosteroids and supportive therapy. At the onset of therapeutic intervention, the patient presented with erythematous patches accompanied by vesicular lesions spanning almost the entirety of his body. Subsequently, platelet concentrate transfusions were administered on the fourth and sixth days of treatment, with a total of eight bags administered on each occasion. On the eighth day of treatment, a histopathological exam showed that the patient had bullous pemphigoid because there was necrotic epithelium and chronic inflammatory cells. The decision to forgo direct immunofluorescent assay (DIF) was predicated upon the patient’s existing thrombocytopenia and heightened vulnerability to bleeding complications. Subsequently, on the twelfth day of treatment, the patient underwent a transfusion of one unit of packed red cells (PRC). Following this, on the thirteenth day of treatment, the patient received two units of PRC and eight units of platelet concentrates. On the fourteenth day of treatment, the patient experienced an abrupt loss of consciousness, preceded by a severe headache and anisocoric pupils. Laboratory findings revealed a post-transfusion platelet count of 7000/ul after eight bags of platelets were administered. Despite continued therapeutic interventions.", "summary": "A 23-year-old male with ALL-L1 diagnosis who developed bullous pemphigoid in this report. The patient exhibited typical ALL-L1 symptoms, including constitutional manifestations and signs of bone marrow compromise. Dermatological assessment revealed extensive edematous urticaria-like plaques, erosions, excoriations, crusts, and a hemorrhagic bulla. Severe thrombocytopenia was evident in laboratory tests, with histopathological examination confirming bullous pemphigoid. Despite aggressive treatment, including platelet transfusions, the patient's condition worsened.", "subclaim_evaluations": [ { "subclaim": "The patient is a 23-year-old male.", "support_label": "supported" }, { "subclaim": "The patient has an ALL-L1 diagnosis.", "support_label": "supported" }, { "subclaim": "The patient developed bullous pemphigoid.", "support_label": "supported" }, { "subclaim": "The patient exhibited constitutional manifestations.", "support_label": "supported" }, { "subclaim": "The patient had signs of bone marrow compromise.", "support_label": "supported" }, { "subclaim": "Dermatological assessment revealed extensive edematous urticaria-like plaques.", "support_label": "supported" }, { "subclaim": "Dermatological assessment revealed erosions.", "support_label": "supported" }, { "subclaim": "Dermatological assessment revealed excoriations.", "support_label": "supported" }, { "subclaim": "Dermatological assessment revealed crusts.", "support_label": "supported" }, { "subclaim": "Dermatological assessment revealed a hemorrhagic bulla.", "support_label": "supported" }, { "subclaim": "Severe thrombocytopenia was evident in laboratory tests.", "support_label": "supported" }, { "subclaim": "Histopathological examination confirmed bullous pemphigoid.", "support_label": "supported" }, { "subclaim": "The patient received platelet transfusions.", "support_label": "supported" }, { "subclaim": "The patient's condition worsened despite treatment.", "support_label": "supported" } ] }, { "id": "multiclinsum_test_2870_en.txt", "fulltext": "A 30-year-old Korean woman was diagnosed with suspicious papillary thyroid carcinoma (PTC) by fine needle aspiration (FNA) at a local medical clinic. She was referred to our hospital for operation. She has no personal or family history of thyroid dysfunction and no specific medication history. Physical examination of neck revealed a diffusely enlarged and non-tender thyroid gland. There were no palpable cervical lymph nodes. US was carried out using a real time linear array 10-MHz transducer. The thyroid US demonstrated a diffusely enlarged thyroid gland with a 0.4×0.3cm sized hypoechoic nodule in the left thyroid . She wanted to diagnose the thyroid nodule again in our hospital. US-guided FNA was performed again on that nodule, and FNA cytology was diagnosed as suspicious PTC. We also examined for BRAF V600E mutation using FNA cytology materials. BRAF V600E mutation was identified by multiplex real time polymerase chain reaction assay using Anyplex™ BRAF V600E Real Time Detection (V2.0) (Seegene, Inc., Seoul, Korea), which allows for simultaneous amplification of total nucleic acid of V600E mutation of BRAF and internal control (human β globin gene). Computed tomography scan using contrast agent was done three weeks before operation. No abnormal finding was noted. The patient had no thyrotoxic symptoms during one month of the preoperative period. She underwent a left thyroid lobectomy by endoscopic thyroidectomy via a transaxillary approach for the thyroid tumor. The right thyroid was not manipulated during operation. Pathologic finding revealed a papillary carcinoma, and other portions of the thyroid parenchyma revealed lymphocytic patches predominantly in peripheral portions. There were rarely lymphoid follicles with germinal center .\nOn laboratory examination, the preoperative laboratory test was performed one month before operation was within normal limits. The serial change of thyroid function tests and the titer of autoantibodies were summarized in Table . On postoperative day (POD) 1, she didn’t definitive complain. A thyroid function test (TFT) showed hyperthyroid with Antithyroglobulin antibody and thyroglobulin (Tg) . On POD 8, the patient was consulted by the department of endocrinology. On physical examination, blood pressure was 120/80mmHg, and heart rate was 119beat/min and regular. Neck examination revealed no sign of tenderness and redness. TFT was still increased but Tg level was normalized . Tc-99m scintigraphy showed faint visualization of the right thyroid lobes, and 24-hour radioactive uptake of 131I was 0.7% , which suggested destructive thyroiditis. On POD 48, thyroid function tests revealed euthyroid. On POD 86, she complained of fatigue and weakness. A TFT revealed hypothyroidism . The patient was treated with levothyroxine for her symptoms of hypothyroidism. On POD 140, follow-up TFT revealed mild hyperthyroidism . The patient was treated with levothyroxine.", "summary": "A 30-year-old Korean woman was referred to our center for thyroid tumor operation. She was diagnosed with suspicious papillary thyroid carcinoma by fine needle aspiration at a local medical clinic. The thyroid ultrasonography demonstrated a diffusely enlarged thyroid gland with a 0.4×0.3cm sized hypoechoic nodule in the left lobe. Left thyroid lobectomy by endoscopic thyroidectomy was performed via a transaxillary approach, and the nodule was confirmed to be a papillary thyroid carcinoma. On postoperative day 1, a thyroid function test revealed hyperthyroidism, and on postoperative day 8, a thyroid function test again revealed hyperthyroidism with decreased radioactive iodine uptake. Thyroid function tests showed euthyroid on postoperative day 48 and hypothyroidism on postoperative day 86. She was treated with levothyroxine.", "subclaim_evaluations": [ { "subclaim": "The patient is a 30-year-old Korean woman.", "support_label": "supported" }, { "subclaim": "She was referred for thyroid tumor operation.", "support_label": "supported" }, { "subclaim": "She was diagnosed with suspicious papillary thyroid carcinoma by fine needle aspiration.", "support_label": "supported" }, { "subclaim": "The diagnosis was made at a local medical clinic.", "support_label": "supported" }, { "subclaim": "Thyroid ultrasonography showed a diffusely enlarged thyroid gland.", "support_label": "supported" }, { "subclaim": "The thyroid nodule was 0.4×0.3cm in size.", "support_label": "supported" }, { "subclaim": "The nodule was located in the left lobe.", "support_label": "supported" }, { "subclaim": "The nodule was hypoechoic.", "support_label": "supported" }, { "subclaim": "Left thyroid lobectomy was performed.", "support_label": "supported" }, { "subclaim": "The surgery was performed via a transaxillary approach.", "support_label": "supported" }, { "subclaim": "The nodule was confirmed to be papillary thyroid carcinoma.", "support_label": "supported" }, { "subclaim": "On postoperative day 1, a thyroid function test revealed hyperthyroidism.", "support_label": "supported" }, { "subclaim": "On postoperative day 8, a thyroid function test again revealed hyperthyroidism.", "support_label": "supported" }, { "subclaim": "On postoperative day 8, radioactive iodine uptake was decreased.", "support_label": "supported" }, { "subclaim": "Thyroid function tests showed euthyroid on postoperative day 48.", "support_label": "supported" }, { "subclaim": "Thyroid function tests showed hypothyroidism on postoperative day 86.", "support_label": "supported" }, { "subclaim": "She was treated with levothyroxine.", "support_label": "supported" } ] }, { "id": "multiclinsum_test_2096_en.txt", "fulltext": "A 20-year-old female with no significant past medical history presented with progressive weakness of the right lower limb for 7 months with tingling and numbness of the same limb for 6 months. The weakness in her limb was insidious in onset, which was initially noticed by slipping of slippers but gradually progressed to the point that she needed support while walking. She had a history of mild back pain for 1 month. Her bowel and bladder habits were normal. She had no history of shortness of breath, difficulty swallowing, blurring of vision, double vision, auditory disturbances, abnormal body movements, or trauma of any kind. She had no family history of malignancy or other tumors.\nHer general condition was fair, her vitals were stable, and there were no positive findings on the general examination. The findings of higher mental function examination and other neurological examinations were within normal limits. Other neurological examination findings have been depicted in Table .\nWith this history and examination in mind, we suspected the possibility of a mass compressing the spinal cord clinically. Subsequently, MRI scans of her spine and brain were conducted to identify any apparent pathology.", "summary": "We describe a case of a 20-year-old female presenting with progressive weakness of the right lower limb for 7 months with a tingling sensation and numbness of the same limb for 6 months and was found to have schwannomatosis with multiple spinal and right cerebellopontine angle (CPA) (9th/10th cranial nerve) schwannomas and left anterior cranial fossa meningioma.", "subclaim_evaluations": [ { "subclaim": "The patient is a 20-year-old female.", "support_label": "supported" }, { "subclaim": "She had progressive weakness of the right lower limb for 7 months.", "support_label": "supported" }, { "subclaim": "She had a tingling sensation in the right lower limb for 6 months.", "support_label": "supported" }, { "subclaim": "She had numbness in the right lower limb for 6 months.", "support_label": "supported" }, { "subclaim": "She was found to have schwannomatosis.", "support_label": "not_supported" }, { "subclaim": "She had multiple spinal schwannomas.", "support_label": "not_supported" }, { "subclaim": "She had a right cerebellopontine angle schwannoma.", "support_label": "not_supported" }, { "subclaim": "The right CPA schwannoma involved the 9th/10th cranial nerves.", "support_label": "not_supported" }, { "subclaim": "She had a left anterior cranial fossa meningioma.", "support_label": "not_supported" } ] }, { "id": "multiclinsum_test_350_en.txt", "fulltext": "A 63-year-old woman with chronic hepatitis B virus infection was referred to our clinic due to incidental detection of a hepatic mass. Alpha-fetoprotein and protein induced by vitamin K absence or antagonist II (PIVKA II) levels were 25.24 ng/mL and 3021 mAU/mL, respectively. The patient was diagnosed with HCC in December 2014. Thereafter, she underwent hand-assisted laparoscopic partial hepatectomy for a solitary tumor with 5 cm in diameter in the right posterior sector. Pathological findings showed that the lesion was 40 mm in size, moderately differentiated, solitary HCC without any macroscopic vascular invasion (T1bN0M0 and stage IB, based on the 8th Union for International Cancer Control staging of HCC). Liver fibrosis was evident during initial surgery (METVIR F2-3).\nSix months after initial surgery, multiple recurrent lesions in the liver were observed. Consequently, the patient was treated with lipiodol-transcatheter arterial chemoembolization (TACE). After this successful TACE, sorafenib (400 mg per day) was administered. Six months later, she underwent laparoscopic left adrenalectomy for adrenal metastasis (pathology revealed metastatic, moderately differentiated HCC). Eight months after the adrenalectomy, the patient underwent laparoscopic partial hepatectomy for a solitary recurrence in the lateral sector (pathology revealed moderately differentiated HCC, background liver condition; METAVIR F3). Eight months after the second hepatectomy, the patient was treated with sorafenib (400 mg per day, followed by 600 mg per day) for increased PIVKA II levels. Despite 9-mo treatment with sorafenib, she was found to have a 43-mm mass in the spleen and portal vein tumor thrombosis (PVTT) that involved both the right and left portal branches down to the main trunk (Vp4) on computed tomography (CT) .\nHepatitis B infection.\nHer personal and family history was unremarkable.\nHer vital signs were normal. There were no remarkable findings other than abdominal distention.\nPIVKA II levels increased tremendously up to 46.291 mAU/mL. The BCLC staging system classified the patient into stage C. Aspartate aminotransferase, alanine aminotransferase, and platelet count were 49 IU/L, 40 IU/L, and 14.7 × 104/μL, respectively. The FIB-4 index was calculated as 3.71, suggesting that she was likely to be cirrhotic. Her cirrhosis was classified into Child-Pugh B (8) and modified albumin-bilirubin grade 1.\nCT findings revealed moderate ascites, which indicated portal hypertension due to tumor thrombosis. This also demonstrated irregularity of the external contour of the left lobe of the liver, suggesting cirrhosis.", "summary": "A 63-year-old woman with chronic hepatitis B virus infection was diagnosed with HCC. Subsequently, she underwent two rounds of laparoscopic partial hepatectomy, laparoscopic left adrenalectomy, and transcatheter arterial chemoembolization plus sorafenib for recurrence. Four years after initial hepatectomy, she presented with a 43-mm mass in the spleen and tumor thrombus involving the main portal vein trunk with ascites. Her liver function was Child-Pugh B (8), and protein induced by vitamin K absence or antagonist II (PIVKA II) levels were elevated up to 46.291 mAU/mL. Since initial treatment with regorafenib for three months was unsuccessful, the patient was administered lenvatinib. Ten months post-treatment, there was no contrast enhancement of PVTT or splenic metastasis. Chemotherapy was discontinued due to severe diarrhea. Afterward, splenic metastasis became viable, and PIVKA II increased. Therefore, hand-assisted laparoscopic splenectomy was performed. She experienced no clinical recurrence 14 mo after resection.", "subclaim_evaluations": [ { "subclaim": "The patient is a 63-year-old woman.", "support_label": "supported" }, { "subclaim": "She has chronic hepatitis B virus infection.", "support_label": "supported" }, { "subclaim": "She was diagnosed with hepatocellular carcinoma (HCC).", "support_label": "supported" }, { "subclaim": "She underwent two rounds of laparoscopic partial hepatectomy.", "support_label": "supported" }, { "subclaim": "She underwent laparoscopic left adrenalectomy.", "support_label": "supported" }, { "subclaim": "She received transcatheter arterial chemoembolization.", "support_label": "supported" }, { "subclaim": "She received sorafenib for recurrence.", "support_label": "supported" }, { "subclaim": "Four years after initial hepatectomy, she presented with a 43-mm mass in the spleen.", "support_label": "supported" }, { "subclaim": "There was tumor thrombus involving the main portal vein trunk.", "support_label": "supported" }, { "subclaim": "She had ascites.", "support_label": "supported" }, { "subclaim": "Her liver function was Child-Pugh B (8).", "support_label": "supported" }, { "subclaim": "Her PIVKA II levels were elevated up to 46.291 mAU/mL.", "support_label": "supported" }, { "subclaim": "Initial treatment with regorafenib for three months was unsuccessful.", "support_label": "not_supported" }, { "subclaim": "The patient was administered lenvatinib.", "support_label": "not_supported" }, { "subclaim": "Ten months post-treatment, there was no contrast enhancement of PVTT.", "support_label": "not_supported" }, { "subclaim": "There was no contrast enhancement of splenic metastasis.", "support_label": "not_supported" }, { "subclaim": "Chemotherapy was discontinued due to severe diarrhea.", "support_label": "not_supported" }, { "subclaim": "Splenic metastasis became viable.", "support_label": "supported" }, { "subclaim": "PIVKA II increased.", "support_label": "supported" }, { "subclaim": "Hand-assisted laparoscopic splenectomy was performed.", "support_label": "not_supported" }, { "subclaim": "She experienced no clinical recurrence 14 months after resection.", "support_label": "not_supported" } ] }, { "id": "multiclinsum_test_2466_en.txt", "fulltext": "A 55-year-old female patient was referred to the orofacial pain unit of the OPH clinic for showing symptoms of temporomandibular joint arthralgia and osteoarthritis, orofacial myofascial pain, and sleep bruxism. An experienced Orofacial Pain Specialist performed a comprehensive clinical history and examination following the Diagnostic Criteria for Temporomandibular Disorders (DC/TMD) protocol and the International Classification of Orofacial Pain-1 (ICOP-1) criteria. At the moment of the examination, the patient was taking 150 mg of Venlafaxine for major depressive disorder, 4 mg of Clonazepam for sleep onset insomnia, and hormone replacement therapy for menopause.\nAnother major complaint of the patient was difficulty initiating and maintaining sleep. Thus, an Epworth Sleepiness Scale and Insomnia Severity Index were performed to complete the sleep evaluation. Due to the high scores presented by the patient and clinical history consistent with chronic sleep insomnia, polysomnography (PSG) was requested Even though the PSG revealed no sleep breathing disorders, the exam showed severe modifications in the patient’s sleep architecture, a mild increase in the arousal index, and low-frequency sleep bruxism. The PSG results led us to hypothesize that the patient’s sleep architecture alterations were because of the chronic consumption of benzodiazepines. Thus, the patient was derived to her treating psychiatrist to gradually diminish and eliminate the intake of Clonazepam.\nDuring this time, the patient successfully underwent her osteoarthritis and orofacial myofascial pain treatment. In addition, an upper oral occlusal splint was prescribed to manage low-frequency sleep bruxism.\nIn order to manage sleep initiation and maintenance insomnia, the psychiatrist tapered the dosage of Clonazepam and progressively replaced it with Trazodone until a target dose of 100 mg was reached. Throughout this period, the patient did not experience any extrapyramidal symptoms.\nAlmost three months later, after the end of the orofacial pain treatment, the patient returned complaining of a sudden worsening of her awake bruxism. The patient presented abrupt rhythmic involuntary muscle contractions, similar to jaw-closing and jaw-deviating dystonic-like movements affecting the right side of her masticatory muscles. (See , and ) The dystonic-like episodes were spontaneous or triggered by everyday activities such as talking, chewing, and yawning. The severity of these motor contractions tended to be exacerbated by emotional stress and nervousness produced by these uncontrollable movements. During these episodes, some typical features of oromandibular dystonia were noticed, such as some sensory tricks (gentle pressure on the inferior incisors would milden the jaw-deviating dystonia as the placement of a tongue depressor between the molars for jaw-closing dystonia), and phenomena (e.g., oromandibular dystonia overflowing the right eyelid, resulting in right blepharospasm).\nA video examination protocol suggested by Yoshida was carried out to assess the type and magnitude of involuntary movements . In addition, a complete haematological and biochemical blood examination was required and all the parameters were within normal range. Thus, both thyroid and parathyroid hormonal dysfunction were ruled out.\nSince the literature indicates that Trazodone can induce extrapyramidal symptoms and abnormal oromandibular movement disorders only start after the addition of this medication. The authors, in agreement with her treating physician, suggested performing a slow taper until complete discontinuation of Trazodone was achieved.\nA progressive dose reduction of 25 mg of Trazodone was scheduled every two weeks. In the meantime, an inferior occlusal splint was prescribed, considering that mild contact in the inferior incisor tended to ease the intensity of the dystonic-like movements.\nDuring the progressive discontinuation of Trazodone, the authors noticed an immediate attenuation of the dystonic symptoms. However, only achieving a partial but clear remission of them. No video protocol was recorded during the tampering of Trazodone.\nConsidering that the patient’s mental health status was stable, it was decided to take a more conservative approach, only eliminating the most likely offending drug, namely, Trazodone. Consequently, the authors maintained that Venlafaxine intake was unchanged in order not to jeopardize the psychiatric treatment, and also closely monitored the evolution of the clinical symptoms. Additionally, the authors indicated the administration of 25 units of incobotulium toxin (Xeomin®, Merz, Germany) per masseter muscle, 20 units per temporalis muscle, and 15 units were applied to the inferior head of the right lateral pterygoid with electrical stimulation guidance (See anatomical landmarks in ).\nDuring the two-week follow-up consultation, the authors could recognize a substantial decrease in the magnitude and intensity of the oromandibular movement. Two months and seven months after the discontinuation of the offending drug and botulinum toxin application, the authors re-recorded Yoshida’s video protocol to carry out an objective before and after comparison of the treatment results. See for comparison prior to and after the treatment.", "summary": "The authors will present a clinical case and management, from the dental specialist perspective, of a 55-year-old female patient who developed tardive oromandibular dystonia induced by Trazodone prescribed for sleep insomnia.", "subclaim_evaluations": [ { "subclaim": "The patient is a 55-year-old female.", "support_label": "supported" }, { "subclaim": "The patient developed tardive oromandibular dystonia.", "support_label": "supported" }, { "subclaim": "The dystonia was induced by Trazodone.", "support_label": "supported" }, { "subclaim": "Trazodone was prescribed for sleep insomnia.", "support_label": "supported" }, { "subclaim": "The authors will present a clinical case and management.", "support_label": "supported" }, { "subclaim": "The case is presented from the dental specialist perspective.", "support_label": "supported" } ] }, { "id": "multiclinsum_test_467_en.txt", "fulltext": "A 70-year-old woman was diagnosed as having PD at 65 years of age after having difficulty with walking and clumsiness with her hands. She also had olfactory impairment. She had no family history of PD. Examinations revealed asymmetric parkinsonism with limb rigidity and bradykinesia that were more prominent on the left. There were no cerebellar signs or gaze palsy. Her Hoehn and Yahr stage was 2 and her Mini-Mental State Examination score was 30. Magnetic resonance imaging of her brain revealed normal findings. She was initially treated with levodopa (L-dopa), (200 mg/day), which markedly improved her symptoms. A reduced meta-iodobenzylguanidine (MIBG) cardiac uptake on myocardial scintigraphy was detected. On the basis of these findings, she was diagnosed as having PD. At 67 years of age, she developed orthostatic hypotension and was treated sequentially with fluids, compression stockings, and midodrine. Her disease slowly progressed over the next three years, and L-dopa dosage was increased to 600 mg/day. At 70 years of age, she had a mild head trauma with loss of consciousness. One month later, she developed acute-onset lateral flexion of her trunk to the left side while standing, and she was admitted to our hospital. On admission, her neurological examinations revealed slight weakness of her left upper and lower extremities in both proximal and distal muscles, as indicated by her Medical Research Council (MRC) scale score of 5-/5. She showed a sustained 10.1°lateral flexion of her trunk to the left side on standing . This posture was alleviated in the supine position. Her Pisa angle was assessed using NeuroPostureApp© . Her right muscle strength was normal. Her sensory systems were normal and no cerebellar signs were detected. Her deep tendon reflexes were normal and her plantar reflex was flexor bilaterally. Her presurgical brain computed tomography (CT) showed CSDH in the right hemisphere resulting in a marked compression of the hemisphere . She was immediately referred to the neurosurgical department of our hospital and the subdural hematoma was successfully evacuated by single-burr-hole drainage. Her brain CT carried out four days after the operation showed improvement of her subdural hematoma . Seven days after her operation, her PS disappeared and she fully recovered to her preoperative level of function without any sequelae such as headaches and cognitive impairment caused by her CSDH. She is still being follow-up.", "summary": "A 70-year-old woman developed acute-onset lateral flexion of her trunk to the left side while standing, and she was admitted to our hospital. One month before, she had a mild head trauma with loss of consciousness. At 65 years of age, she noticed difficulty with walking and clumsiness with her hands. She was diagnosed as having PD (Hoehn and Yahr stage 2) and levodopa was initiated. Her symptoms were markedly improved. At 67 years of age, she developed orthostatic hypotension and was treated sequentially with fluids, compression stockings, and midodrine. Urgently performed brain computed tomography (CT) showed a CSDH in the right hemisphere resulting in a marked compression of the hemisphere. After surgical evacuation, her PS disappeared. She has fully recovered to her preoperative level of function.", "subclaim_evaluations": [ { "subclaim": "The patient is a 70-year-old woman.", "support_label": "supported" }, { "subclaim": "She developed acute-onset lateral flexion of her trunk to the left side while standing.", "support_label": "supported" }, { "subclaim": "She was admitted to the hospital.", "support_label": "supported" }, { "subclaim": "One month before admission, she had a mild head trauma with loss of consciousness.", "support_label": "not_supported" }, { "subclaim": "At 65 years of age, she noticed difficulty with walking.", "support_label": "supported" }, { "subclaim": "At 65 years of age, she noticed clumsiness with her hands.", "support_label": "supported" }, { "subclaim": "She was diagnosed as having Parkinson's disease.", "support_label": "supported" }, { "subclaim": "Her Parkinson's disease was classified as Hoehn and Yahr stage 2.", "support_label": "supported" }, { "subclaim": "Levodopa was initiated.", "support_label": "supported" }, { "subclaim": "Her symptoms were markedly improved.", "support_label": "supported" }, { "subclaim": "At 67 years of age, she developed orthostatic hypotension.", "support_label": "supported" }, { "subclaim": "She was treated with fluids.", "support_label": "supported" }, { "subclaim": "She was treated with compression stockings.", "support_label": "supported" }, { "subclaim": "She was treated with midodrine.", "support_label": "supported" }, { "subclaim": "Urgently performed brain CT showed a chronic subdural hematoma in the right hemisphere.", "support_label": "supported" }, { "subclaim": "The chronic subdural hematoma caused marked compression of the right hemisphere.", "support_label": "supported" }, { "subclaim": "After surgical evacuation, her postural symptoms disappeared.", "support_label": "supported" }, { "subclaim": "She has fully recovered to her preoperative level of function.", "support_label": "supported" } ] }, { "id": "multiclinsum_test_2409_en.txt", "fulltext": "A 55-year-old man, with body mass index (BMI) of 18.36 kg/m2, was admitted into our hospital for left hip pain for 6 months. The symptom started with moderate pain after walking. Over the last few days, the pain got worsen with no remission after rest. The patient denied any history of trauma, glucocorticoid hormone consumption or radiotherapy. Examinations before admission revealed old fracture on the left femoral neck and an increase in blood uric acid. After admission, the function evaluations of his bilateral hip joint were summarized as follows: Visual Analogue Scale (VAS) score was 4, Harris score was 23 in the left hip joint, while VAS score was 0, Harris score was 90 in the right hip joint. The imaging examinations of the pelvis, including radiographs , CT and MRI scan , confirmed the existence of bilateral femoral neck fractures, with fracture nonunion and femoral neck shortening in his left femoral neck and double fracture lines in his right femoral neck. The Dual energy X-ray absorptiometry (DXA) examination of the lumbar spine showed reduced bone mineral density (BMD) and severe osteoporosis (L1–L4: BMD0.514 g/cm2, T score = − 4.6). In addition, tumor markers, tuberculosis antibodies, alkaline phosphatase and parathyroid hormone levels were found to be normal.\nWe recommended a left cementless THA, and a cannulated screws fixation on the right side. And the uric acid lowering treatment was performed on the patient. However, the patient only agreed to the left THA, while on the right side, conservative treatment was selected for patient because of financial reasons. The left THA through the lateral approach was performed for the patient under general anesthesia . During the surgery, we found sclerosis, fatty degeneration and necrosis of the fracture end of the left femoral neck . We used impactive bone grafting to strengthen the acetabular on the fracture region .\nAfter the operation, the patient was treated with 20 U Elcatonin injection (Sidinuo®, Shangdong Luye Pharmaceutical Co.LTD, Yantai, China) once a week, and 1 tablet of Calcium Carbonate D3 Granules (Langdi®, Beijing Kangyuan Pharmaceutical CO.LTD, Beijing, China) containing calcium carbonate (500 mg) and vitamin D (200 IU), twice a day. Meanwhile, He was required to exercise his quadriceps and calf muscle on bed, move with the help of wheelchairs, and avoid walking on crutches. The postoperative histological examination, as showed in Fig. , revealed that the left fracture gap was filled with fibrous tissues, with few new bone tissues and a large amount of necrotic bone tissue observed. Meanwhile, the plain radiograph of the pelvis one day after surgery revealed that the total hip replacement arthroplasty was very successful . Generally, the patient recovered well during the hospitalization and was successively discharged home.\nFour months after discharge, the radiograph image showed no signs of implant loosening or infection in his left hip . It was worth noting that CT images revealed fracture union of the right femoral neck, as shown in Fig. b and Fig. c. In addition, function evaluations of his bilateral hips at four months after surgery was satisfactory and summarized as follows: VAS score was 0, Harris score was 98 in the left hip joint and VAS score was 0, Harris score was 95 in the right hip joint.", "summary": "A 55-year-old male patient complained pain in his bilateral hip, with no history of trauma, glucocorticoid hormone consumption or radiotherapy, and imaging examination revealed fracture nonunion and shortening in his left femoral neck, and double fracture line on the right femoral neck. The patient received a cementless THA for the left femoral neck fracture and conservative treatment for the right side, followed by Elcatonin injection and oral administration of Carbonate D3 Granules. After 4 months of fellow-up, the patient presented improved functional scorings in bilateral hip joints, with no signs of prothesis infection or loosening.", "subclaim_evaluations": [ { "subclaim": "The patient is a 55-year-old male.", "support_label": "supported" }, { "subclaim": "The patient complained of pain in his bilateral hip.", "support_label": "supported" }, { "subclaim": "The patient had no history of trauma.", "support_label": "supported" }, { "subclaim": "The patient had no history of glucocorticoid hormone consumption.", "support_label": "supported" }, { "subclaim": "The patient had no history of radiotherapy.", "support_label": "supported" }, { "subclaim": "Imaging examination revealed fracture nonunion in the left femoral neck.", "support_label": "supported" }, { "subclaim": "Imaging examination revealed shortening in the left femoral neck.", "support_label": "supported" }, { "subclaim": "Imaging examination revealed a double fracture line on the right femoral neck.", "support_label": "supported" }, { "subclaim": "The patient received a cementless total hip arthroplasty for the left femoral neck fracture.", "support_label": "supported" }, { "subclaim": "The patient received conservative treatment for the right femoral neck fracture.", "support_label": "supported" }, { "subclaim": "The patient received Elcatonin injections.", "support_label": "supported" }, { "subclaim": "The patient received oral administration of Carbonate D3 Granules.", "support_label": "supported" }, { "subclaim": "After 4 months of follow-up, the patient had improved functional scorings in bilateral hip joints.", "support_label": "supported" }, { "subclaim": "After 4 months of follow-up, there were no signs of prosthesis infection.", "support_label": "supported" }, { "subclaim": "After 4 months of follow-up, there were no signs of prosthesis loosening.", "support_label": "supported" } ] }, { "id": "multiclinsum_test_829_en.txt", "fulltext": "A 27-year-old man presented to the Department of Spine Surgery of our hospital with complaints of neck pain, limb numbness, and weakness.\nHis symptoms started suddenly, 4 d prior to hospital presentation.\nThe patient had no trauma history. A similar episode of transient limb numbness and weakness occurred 6 years earlier.\nHe denied any personal or family history of other diseases.\nPhysical examination revealed tenderness of the paraspinal muscle of the C6-T1 spinous process, muted sensory responsiveness to touch along the T1 dermatome, and grade IV muscle strength in the four limbs.\nThe results of all blood analyses — including coagulation markers, inflammatory indicators, and tumor markers — were within normal limits.\nSpinal radiography and computed tomography demonstrated no obvious bone destruction. Enhanced cervical magnetic resonance imaging (MRI) showed a homogenously enhanced epidural mass in the C6-T1 spinal canal. The mass compressed the spinal cord and extended into the left C7-T1 foramen. It appeared hypointense on T1-weighted images (T1WIs) and hyperintense on T2WI. Moreover, a 0.5 cm × 0.5 cm × 0.6 cm-sized heterogeneously enhanced hyperintense mass was found in the C7 vertebral body on T2WI, which was suggestive of a benign vertebral hemangioma (VH) .", "summary": "A 27-year-old man presented with acute-onset neck pain, numbness, and weakness in his extremities. Magnetic resonance imaging showed an epidural mass in the cervicothoracic (C6-T1) spinal canal and vertebral hemangioma (VH) involving the C7 vertebral body. C6-T1 Laminectomy and radical excision of the mass were performed. Histopathological examinations revealed papillary proliferation of vascular endothelial cells with thrombus formation, and an IPEH diagnosis was made. By his 6-mo follow-up appointment, his symptoms were relieved without recurrence. The possible pathogenesis, clinical and imaging features, differential diagnosis, and management of IPEH were reviewed.", "subclaim_evaluations": [ { "subclaim": "The patient is a 27-year-old man.", "support_label": "supported" }, { "subclaim": "He presented with acute-onset neck pain.", "support_label": "supported" }, { "subclaim": "He had numbness in his extremities.", "support_label": "supported" }, { "subclaim": "He had weakness in his extremities.", "support_label": "supported" }, { "subclaim": "Magnetic resonance imaging showed an epidural mass in the cervicothoracic spinal canal.", "support_label": "supported" }, { "subclaim": "The epidural mass was located at C6-T1.", "support_label": "supported" }, { "subclaim": "The mass was in the spinal canal.", "support_label": "supported" }, { "subclaim": "The mass was vertebral hemangioma.", "support_label": "supported" }, { "subclaim": "The vertebral hemangioma involved the C7 vertebral body.", "support_label": "supported" }, { "subclaim": "C6-T1 laminectomy was performed.", "support_label": "not_supported" }, { "subclaim": "Radical excision of the mass was performed.", "support_label": "supported" }, { "subclaim": "Histopathological examination showed papillary proliferation of vascular endothelial cells.", "support_label": "not_supported" }, { "subclaim": "Histopathological examination showed thrombus formation.", "support_label": "not_supported" }, { "subclaim": "The diagnosis was intraspinal epidural hemangioma (IPEH).", "support_label": "supported" }, { "subclaim": "By the 6-month follow-up, his symptoms were relieved.", "support_label": "not_supported" }, { "subclaim": "There was no recurrence at the 6-month follow-up.", "support_label": "not_supported" }, { "subclaim": "The possible pathogenesis of IPEH was reviewed.", "support_label": "not_supported" }, { "subclaim": "The clinical features of IPEH were reviewed.", "support_label": "not_supported" }, { "subclaim": "The imaging features of IPEH were reviewed.", "support_label": "supported" }, { "subclaim": "The differential diagnosis of IPEH was reviewed.", "support_label": "not_supported" }, { "subclaim": "The management of IPEH was reviewed.", "support_label": "not_supported" } ] }, { "id": "multiclinsum_test_3164_en.txt", "fulltext": "A 79-year-old Caucasian man presented to the emergency room with shortness of breath, bilateral leg oedema and fatigue. His medical history was notable for arterial hypertension and degenerative valve disease, with indication of aortic valve replacement which he refused. He did not use alcohol, tobacco or illicit drugs. There was no history of recent infection, or any invasive procedure in the last year. Besides taking antihypertensive drugs, he was not on any medications. He had not been consulted by a physician in the last 3 years.\n\nOn physical examination, he was afebrile, with bilateral lower extremity oedema, there was arrhythmia with a heart rate of 70/min, blood pressure was 180/80 mm Hg; there was a grade 5/6 systolic murmur at the aortic area, and a grade 4/6 holosystolic murmur at the mitral area. Respiratory examination revealed dullness to conventional percussion, decreased tactile fremitus and decreased breath sounds at the bilateral lung bases with crackles. The remainder of the exam was unremarkable.\n\n\nInvestigations\n\nStandard 12-lead ECG showed atrial fibrillation with heart rate between 60–70 beats/min and left ventricular hypertrophy signs with secondary repolarisation changes.\n\nThe chest X-ray showed cardiomegaly with interstitial densities and pulmonary venous congestion. Large bilateral pleural effusions were noted.\n\nThe chemistry panel showed an N-terminal pro b-type natriuretic peptide level of 2000 pg/mL, increased creatinine with an estimated glomerular filtration rate of 30 mL/min/1.73 m2, high blood glucose, hyperuricaemia and hyponatraemia. The C reactive protein level was 9 g/dL (normal <5 g/dL), erythrocyte sedimentation rate was 30 mm/hour and the fibrinogen level was 300 mg/dL (normal <500 mg/dL). There was mild normochromic normocytic anaemia (haemoglobin=99 g/L) and leucocyte count was 9710/mm3 with 64% neutrophils, 7% eosinophils, 20% lymphocytes and 9% monocytes. The urinalysis was normal, with negative urine culture. Pharyngeal exudate was positive for Candida spp. and negative for Staphylococcus aureus and Streptococcus pyogenes. Further blood tests were in the normal range.\n\nTransthoracic echocardiography (TTE) showed mild left ventricle hypertrophy. Systolic function was normal with an ejection fraction estimated at about 60%. The right ventricle was mildly enlarged with normal longitudinal function. Both atria showed marked enlargement. The aortic valve was tricuspid with severe stenosis (aortic valve area 0.4 cm2) and moderate regurgitation. The mitral valve showed a mobile hyperechogenic formation with the maximum diameter of 12 mm seen in the left atrium which strongly indicated endocarditis. Doppler examination showed severe mitral regurgitation due to perforation of the mitral anterior leaflet and also moderate tricuspid regurgitation. The inferior vena cava was dilated, and the pulmonary systolic pressure was estimated at about 50 mm Hg.\n\nTransoesophageal echocardiography confirmed the presence of vegetation.\n\nSonography of the abdominal organs was normal.\n\nBefore antibiotic treatment was started, four blood cultures where taken from separate venous sites, at 30 min intervals. Each sample was placed into a pair of blood culture bottles that cultivate aerobic and anaerobic bacteria separately.\n\nThree out of four blood culture grew Gram-positive cocci in clusters. The organism grew on trypticase soy agar and was catalase-positive, oxidase-negative and coagulase-negative. It was identified as coagulase-negative Staphylococcus, and subsequently as S. warneri by the Vitek 2 GP card (BioMérieux). After 72 hours of treatment three other blood cultures were taken randomly and came out negative.\n\n\nTreatment\n\nEmpirical antibiotic treatment with vancomycin 30 mg/kg/day intravenous in three doses and gentamicin 3 mg/kg/day intravenous was started. Afterwards, following the discussion with the infectious disease physician and the microbiologist, we concluded that the isolation of S. warneri was not contamination, and we established the diagnosis of S. warneri endocarditis, based on two major diagnosis criteria—echocardiography and positive blood cultures. The antibiogram revealed resistance to penicillin, tetracycline, erythromycin, clindamycin, clarithromycin, doxycycline, fosfomycin, rifampicin and susceptibility to fusidic acid, ciprofloxacin, daptomycin, gentamicin, vancomycin, levofloxacin, linezolid, moxifloxacin, norfloxacin, ofloxacin, oxacillin, pefloxacin, minocyclin and trimethoprime/sulfamethoxazole. We decided to continue treatment with oxacillin 12 g/day intravenous in four doses according to current guidelines. The patient also received medication for heart failure and was anticoagulated with acenocoumarol for his atrial fibrillation. He was consulted by a psychologist and received sleep pills, for insomnia.\n\n\nOutcome and follow-up\n\nThe patient’s clinical condition improved slowly, with gradual remission of congestion, and decrease of non-specific inflammation markers, and also there was an improvement in kidney function (with a decrease of creatinine from 2.0 to 1.4 mg/dL). He was discharged after 1 month with a good clinical condition. The patient was informed again about the firm indication for mitral and aortic valve replacement, but he refused again the intervention.\n\nOne month after discharge the patient had the same aspect of the TTE, with severe mitral regurgitation but with well-tolerated heart failure (New York Heart Association class II). The chemistry panel showed mild normochromic normocytic anaemia (haemoglobin 112 g/L), and a creatinine level of 1.6 mg/dL.\n\nAfter 3 months he was again hospitalised for decompensated heart failure (pleural effusion and fatigue). All of the five blood cultures taken this time were negative. The symptoms improved after 6 days of intravenous diuretics and the patient was discharged with the same recommendations.\n\nHe is still refusing the valve surgery.", "summary": "We report a rare case of native valve endocarditis caused by Staphylococcus warneri in an immunocompetent 79-year-old man with known degenerative valvular heart disease but no previous risk factors such as recent invasive treatment or medical implant. The patient presented with heart failure, due to perforation of the mitral valve, and lacked any signs of infection. The diagnosis of endocarditis with S. warneri was established by echocardiography and positive blood cultures.", "subclaim_evaluations": [ { "subclaim": "The patient was a 79-year-old man.", "support_label": "supported" }, { "subclaim": "The patient was immunocompetent.", "support_label": "not_supported" }, { "subclaim": "The patient had degenerative valvular heart disease.", "support_label": "supported" }, { "subclaim": "The patient had no previous risk factors for endocarditis.", "support_label": "not_supported" }, { "subclaim": "The patient had no recent invasive treatment.", "support_label": "supported" }, { "subclaim": "The patient had no medical implant.", "support_label": "supported" }, { "subclaim": "The patient presented with heart failure.", "support_label": "supported" }, { "subclaim": "The heart failure was due to perforation of the mitral valve.", "support_label": "supported" }, { "subclaim": "The patient lacked any signs of infection.", "support_label": "not_supported" }, { "subclaim": "The diagnosis was native valve endocarditis.", "support_label": "supported" }, { "subclaim": "The causative organism was Staphylococcus warneri.", "support_label": "supported" }, { "subclaim": "The diagnosis was established by echocardiography.", "support_label": "supported" }, { "subclaim": "Blood cultures were positive for Staphylococcus warneri.", "support_label": "supported" } ] }, { "id": "multiclinsum_test_52_en.txt", "fulltext": "A 37-year-old pregnant woman at 33 wk and 3 d of gestation had been diagnosed with RHD 4 mo ago. She was admitted to the intensive care unit (ICU) of our hospital complaining of orthopnea, anhelation and lower extremity edema.\nThe patient was first diagnosed with RHD at 12 wk of gestation. She developed cardiac enlargement with moderate pulmonary hypertension (PH) at 28 wk of gestation followed by atrial fibrillation (AF) at 29 wk of gestation. At 33 wk of gestation, she experienced severe heart failure which had worsened in the last 24 h.\nThe patient was gravida 5, 1-0-0-0-1, with 3 spontaneous abortions because of embryo hepatocytes. The outcome of her first pregnancy more than 10 years earlier was a natural birth without any discomfort.\nThe patient denied a history of thrombosis, smoking, tuberculosis, and alcohol or drug use. No family members had similar diseases.\nThe patient’s heart rate was 145 beats/min, blood pressure was 113/82 mmHg, respiratory rate was 25 breaths/min, and oxygen saturation by pulse oximetry (SaO2) was 100% on room air. The patient’s current weight was 82 kg, BMI (before pregnancy) was 25.3 kg/m2, a total weight gain was 15 kg during pregnancy. There were no obvious abnormalities in the fetus.\nThe patient’s N-terminal pro brain-type natriuretic peptide was 1880 pg/mL, activated partial thromboplastin time (APTT) was 27.0 s, fibrinogen was 4.45 g/L, and D-dimer was 660 ng/mL. The cardiogram showed AF. The urine analysis and arterial blood gas was normal.\nThe TTE showed RHD with severe mitral regurgitation (MR), mild mitral stenosis, moderate aortic regurgitation (AR), severe tricuspid regurgitation (TR), heart dilatation, left ventricular ejection fraction (LVEF) of 52% and a pulmonary artery systolic pressure (PASP) of 75 mmHg. The patient’s right heart (RH) chamber was enlarged and the left ventricle was hypokinetic. The routine TTE monitoring in pregnancy are shown in Table .\nDuring the CS, the TTE revealed a nascent thrombus that fluttered in a serpentine manner in the IVC after placental removal. The thrombus grew rapidly. From 81 mm at discovery to 155 mm in 18 min. The average growth rate was 4.1 mm/min. At 32 min after discovery, the thrombus detached to the tricuspid valve. At 43 min after discovery, the thrombus detached off to the pulmonary artery, where it fragmented and resulted in acute incomplete bilateral pulmonary embolism, and contemporaneously with the PASP increasing sharply to 93 mmHg, SaO2 decreased to 96%. Moreover, small thrombosis attachment to the mitral valve and left atrial appendage (LAA) were detected. The detailed thrombotic changes are shown in Figure . Postoperative computed tomography angiography showed that the right main pulmonary artery, the middle and lower branch of the right pulmonary artery and its branches, and the left lower branch of the pulmonary artery were embolized . Ultrasonic examination revealed no deep vein thrombus of the lower extremities during the perioperative period.", "summary": "A 37-year-old pregnant woman with rheumatic heart disease (RHD), gravida 5 and para 1 (G5P1), presented for emergency CS at 33 wk and 3 d of gestation under general anesthesia because of acute heart failure, pulmonary hypertension and arrhythmia. After placental removal during CS, TTE revealed a nascent thrombus in the inferior vena cava (IVC) that elongated, detached and fragmented leading to acute thromboembolic events and acute TPE. This report presents the whole process and details of TPE during CS and successful rescue without any sequelae in the patient. This case gives us new ideas for the diagnosis of death or cardiovascular accidents during CS in pregnant women with heart disease and the detailed presentation of the rapid development of TPE may also elucidate new ideas for treatment. This case also highlighted the importance of prophylactic anticoagulation in the management of heart disease during pregnancy.", "subclaim_evaluations": [ { "subclaim": "The patient was a 37-year-old pregnant woman.", "support_label": "supported" }, { "subclaim": "She had rheumatic heart disease.", "support_label": "supported" }, { "subclaim": "She was gravida 5 and para 1.", "support_label": "supported" }, { "subclaim": "She presented for emergency cesarean section at 33 weeks and 3 days of gestation.", "support_label": "supported" }, { "subclaim": "The cesarean section was performed under general anesthesia.", "support_label": "not_supported" }, { "subclaim": "The indication for the cesarean section was acute heart failure.", "support_label": "supported" }, { "subclaim": "The indication for the cesarean section was pulmonary hypertension.", "support_label": "not_supported" }, { "subclaim": "The indication for the cesarean section was arrhythmia.", "support_label": "not_supported" }, { "subclaim": "After placental removal, a nascent thrombus was found in the inferior vena cava.", "support_label": "supported" }, { "subclaim": "The thrombus elongated, detached, and fragmented.", "support_label": "supported" }, { "subclaim": "This led to acute thromboembolic events.", "support_label": "supported" }, { "subclaim": "This led to acute thromboembolic pulmonary embolism.", "support_label": "supported" }, { "subclaim": "The patient underwent therapeutic pulmonary embolectomy.", "support_label": "not_supported" }, { "subclaim": "The patient was successfully rescued without any sequelae.", "support_label": "not_supported" }, { "subclaim": "The case provides new ideas for the diagnosis of death or cardiovascular accidents during cesarean section in pregnant women with heart disease.", "support_label": "supported" }, { "subclaim": "The case highlights the importance of prophylactic anticoagulation in the management of heart disease during pregnancy.", "support_label": "not_supported" } ] }, { "id": "multiclinsum_test_2215_en.txt", "fulltext": "A 24-year-old virgin Persian woman presented with a labial mass that had emerged 12 years earlier and grown gradually in size, but caused no pain or discomfort until recently. Her medical history revealed no evidence of any underlying disease or mental disorder. She had a Bachelor’s degree and was unemployed. Menarche occurred at the age of 11 years, and the patient’s menstrual cycle was regular. She had no family history of breast or gynecological cancer. A pedunculated mass measuring 75 × 44 mm was observed in the upper left labium and looked exactly like a penis. Its texture was relatively soft, the skin temperature normal, and the lesion had clear boundaries with no ulceration . There was no connection between progressive growth of the lesion and the patient’s menstrual cycle. The lesion was asymptomatic during menstruation. The patient sought no medical advice until she experienced discomfort in the genital area and had difficulty standing up and sitting down. At admission, her vital signs were blood pressure 115/75 mmHg, pulse rate 73 beats per minute, temperature 36.8 °C, and O2 at 99%. Chest examination was normal and she was well oriented. Breast and abdominal examinations were normal. Axillary and supraclavicular lymph nodes could not be palpated. The patient reported no pain on palpation and had no enlarged lymph nodes in the groin.\nUltrasonography of the lesion revealed a hyperechoic mass with clearly defined margins, internal echoes, and fibroglandular tissue measuring 70 × 40 mm in size. On pelvic ultrasound, there was no abnormality in the uterus and the ovaries. Blood, urine, and serology tests were normal.\nWe decided to perform a resection of the mass, which was then completely removed under local anesthesia and sedation . The tissue was sent for pathological examination. No postoperative complications were encountered. The patient was discharged from the hospital after a few days.\nThe pathological investigation revealed a benign lesion. It was an accessory breast composed of female breast tissue, with a proliferative and dilated ductus lined with two layers of endothelial and myoepithelial cells in fibrotic stroma, and invaded by mononuclear inflammatory cells . She was reviewed in the gynecology outpatient clinic at 2 weeks, 6 weeks, and 10 months post-surgery. Examinations confirmed full recovery with no evidence of recurrence.", "summary": "We report a 24-year-old virgin Persian woman with a left-sided vulvar mass and no pain or discomfort until shortly before her presentation at our department. Ectopic breast tissue in the vulva was diagnosed. We performed wide local resection of the lesion. Pathological investigation of the lesion confirmed the presence of ectopic breast tissue with secretory changes. She had no specific developmental abnormalities and had no relevant family history. She was followed up for 10 months and had recovered fully by this time.", "subclaim_evaluations": [ { "subclaim": "The patient is a 24-year-old woman.", "support_label": "supported" }, { "subclaim": "The patient is a virgin.", "support_label": "supported" }, { "subclaim": "The patient is Persian.", "support_label": "supported" }, { "subclaim": "The patient had a left-sided vulvar mass.", "support_label": "supported" }, { "subclaim": "The patient had no pain or discomfort until shortly before presentation.", "support_label": "supported" }, { "subclaim": "Ectopic breast tissue in the vulva was diagnosed.", "support_label": "supported" }, { "subclaim": "Wide local resection of the lesion was performed.", "support_label": "supported" }, { "subclaim": "Pathological investigation confirmed the presence of ectopic breast tissue.", "support_label": "supported" }, { "subclaim": "The ectopic breast tissue showed secretory changes.", "support_label": "not_supported" }, { "subclaim": "The patient had no specific developmental abnormalities.", "support_label": "supported" }, { "subclaim": "The patient had no relevant family history.", "support_label": "supported" }, { "subclaim": "The patient was followed up for 10 months.", "support_label": "supported" }, { "subclaim": "The patient had recovered fully by the 10-month follow-up.", "support_label": "supported" } ] }, { "id": "multiclinsum_test_2944_en.txt", "fulltext": "A 69-year-old hypertensive male was transferred to us with traumatic brain injury after sustaining a ground-level fall. On admission, his Glasgow Coma Scale was 12/15 (E4V2M6). CT scan depicted a left temporal hematoma with extensive acute subdural hematoma, diffuse edema and mass effect, and midline shift of 6.6 mm . He was admitted to the special care unit for observation where his GCS dropped to 9/15. He then underwent left-sided emergent DC and was discharged 4 weeks later. At the time of discharge, he was awake, alert, and intermittently following simple commands without gross motor or sensory deficits. His speech was slurred and intermittently, he had mildly agitated behavior (Richmond Agitation Sedation Scale or RASS + 1) with a Modified Rankin Scale of 4.\nOne week later, the patient returned to the hospital with progressively worsening agitation without a decline in consciousness. CT scan showed interval development of the right chronic subdural hematoma with interval resolution of the previous acute hematoma. The hematoma was evacuated through burr-hole craniotomy and drain placement. The procedure was uneventful but after the surgery, his agitation increased (RASS + 3) and cognitive dysfunction did not improve. Mini-Mental Score could not be assessed as his comprehension was not intact. At this point, patient was extensively evaluated for other causes of agitation such as electrolytes disturbances, endocrine abnormalities, infection, sepsis, drug intoxication, or alcohol withdrawal, all workup was within normal limits.\nOn serial CT scans, the right subdural collections decreased and his craniotomy skin flap started to sink. Suspecting “syndrome of trephined” and in view of his persistently unexplained behavioral dysfunction, we planned for early cranioplasty which was performed 6 weeks after the primary procedure . Within 48 h of cranioplasty, his agitation started to improve. On the 4th day, his RASS was + 1.\nAt 6-month follow-up, the patient was found able to walk unattended and only required minimal assistance with his activities of daily living (ADL) (MRS 3). His comprehension had also improved considerably and he was able to follow two-step commands with consistency.", "summary": "An elderly gentleman with traumatic brain injury underwent DC. He later developed a sinking flap and unexplained agitation which responded to cranioplasty by returning to a state of calm. His cognitive function further improved over a period of 6 months. This is an unusual observation reported in this case.", "subclaim_evaluations": [ { "subclaim": "The patient is an elderly gentleman.", "support_label": "supported" }, { "subclaim": "The patient had a traumatic brain injury.", "support_label": "supported" }, { "subclaim": "The patient underwent decompressive craniectomy (DC).", "support_label": "supported" }, { "subclaim": "The patient later developed a sinking flap.", "support_label": "supported" }, { "subclaim": "The patient had unexplained agitation.", "support_label": "supported" }, { "subclaim": "The agitation responded to cranioplasty.", "support_label": "supported" }, { "subclaim": "After cranioplasty, the patient returned to a state of calm.", "support_label": "supported" }, { "subclaim": "The patient's cognitive function improved over 6 months.", "support_label": "supported" }, { "subclaim": "This is an unusual observation reported in this case.", "support_label": "supported" } ] }, { "id": "multiclinsum_test_203_en.txt", "fulltext": "The patient was a 60-year-old male who presented to the emergency department (ED) for a syncopal episode in the setting of ventricular tachycardia while at his cardiologist’s outpatient office. The patient has a past medical history of late presentation anterior ST-segment elevation MI 6 weeks prior to this event. During that time, he reported 1 week of anginal symptoms before his MI. He received two drug-eluting stents in the non-culprit right coronary artery and one in the culprit proximal left anterior descending artery. At time of his prior hospital discharge, echocardiogram demonstrated a left ventricular ejection fraction (LVEF) of 40–45% and an apical thrombus. He received antiplatelet therapy with aspirin 81 mg daily and ticagrelor 90 mg twice daily, as well as rivaroxaban 2.5 mg twice daily for the apical thrombus.\nOn admission following his syncopal event, the patient was haemodynamically stable in normal sinus rhythm on an amiodarone infusion. A physical exam was significant for a prominent and laterally displaced point of maximal impulse, the presence of hepatojugular reflux, and muffled heart sounds.\nLaboratory findings were significant for a haemoglobin of 11.9 g/dL (normal range is 13.5–17.5 g/dL), an NT-pro BNP of 2549 pg/mL (normal value is <300 pg/mL), and a high sensitivity troponin T of 26 ng/L (normal value is <59 ng/L). Initial renal function, electrolytes, and liver function testing were within normal limits. Chest radiography showed an enlarged cardiac silhouette. Electrocardiogram revealed normal sinus rhythm with pathologic Q waves in inferior and anteroseptal leads along with low-voltage QRS complexes with an amplitude <5 mm in the limb leads and 10 mm in the chest leads (see , ). An urgent TTE showed a large circumferential pericardial effusion, severe left ventricular (LV) systolic dysfunction with an LVEF of <15%, and a large apical LVA with pathologic thinning and diastolic deformity ( and , ).\nThe patient was initiated on intravenous amiodarone, and anticoagulation was held in the setting of the pericardial effusion with associated LVA. Urgent diagnostic and therapeutic pericardiocentesis was completed with the removal of 600 mL of sanguineous fluid. Incomplete effusion drainage was noted following the procedure suggesting loculated characteristics of the haemopericardium. Cardiothoracic surgery was consulted given the concern for contained LVA or pseudoaneurysm rupture as the underlying aetiology.\nSubsequent computed tomography angiography (CTA) of the chest showed a moderate volume pericardial effusion and a large lobulated LVA measuring 74 mm × 84 mm × 79 mm without signs of active contrast extravasation into the pericardial space . Cardiac magnetic resonance imaging (cMRI) was suspicious for contained ruptured LVA; it showed striking dilation of the mid to distal LV wall with severe myocardial thinning and difficulty identifying myocardium at the apex ( and , ). Interval development of a large, mobile LV thrombus was also noted. Left heart catheterization revealed patency of all previously placed drug-eluting stents (see , ).\nDuring his hospitalization, the patient remained in the medical intensive care unit for bed rest and haemodynamic monitoring. Cardiothoracic surgery performed excision and repair of the LVA with placement of an LV endovascular patch (see , ). Intraoperative findings include the presence of a small rent at the apex of the aneurysm, which was tightly adhered to the overlying pericardium. Pathology reports confirm partially granular myocardial tissue composition of the specimen.\nPost-operative TTE was notable for an improved LVEF of 61% with continued apical akinesis and small aneurysm with possible small associated thrombus ( and , ). CTA revealed post-surgical changes with resolution of the pericardial effusion without evidence of an LV thrombus . Guideline-directed medical therapy was initiated with metoprolol succinate 25 mg daily, losartan 25 mg daily, and spironolactone 25 mg daily; statin was initially held due to reported intolerance. Oral amiodarone 200 mg daily was continued for 1 month for arrhythmia management. Antithrombic therapy with aspirin 81 mg daily and clopidogrel 75 mg daily was started. Anticoagulation was held in the setting of completed left atrial appendage ligation and without signs of further thrombus.\nThe patient was clinically well without further symptomatic concerns of haemopericardium or heart failure 1 month post-operatively. The patient continued to participate well in his cardiac rehabilitation program and was cleared to return to work.", "summary": "We describe a case of contained rupture of a large left ventricular aneurysm (LVA) presenting with syncope in a 60-year-old male with late presentation myocardial infarction (MI) 6 weeks prior on home triple antithrombotic therapy (TAT). Urgent pericardiocentesis along with imaging techniques including ultrasound, computed tomography angiography (CTA), and cardiac magnetic resonance imaging (MRI) were used for initial diagnosis. Definitive treatment was achieved with excision and repair of the LVA with return to prior functional status 1 month after intervention.", "subclaim_evaluations": [ { "subclaim": "The patient was a 60-year-old male.", "support_label": "supported" }, { "subclaim": "The patient had a late presentation myocardial infarction 6 weeks prior.", "support_label": "supported" }, { "subclaim": "The patient was on home triple antithrombotic therapy.", "support_label": "not_supported" }, { "subclaim": "The patient had a contained rupture of a large left ventricular aneurysm.", "support_label": "supported" }, { "subclaim": "The patient presented with syncope.", "support_label": "supported" }, { "subclaim": "Urgent pericardiocentesis was performed.", "support_label": "supported" }, { "subclaim": "Computed tomography angiography was used for diagnosis.", "support_label": "supported" }, { "subclaim": "Cardiac magnetic resonance imaging was used for diagnosis.", "support_label": "supported" }, { "subclaim": "Definitive treatment was excision and repair of the left ventricular aneurysm.", "support_label": "supported" }, { "subclaim": "The patient returned to prior functional status 1 month after intervention.", "support_label": "supported" } ] }, { "id": "multiclinsum_test_647_en.txt", "fulltext": "A 57-year-old Caucasian man with a smoking habit who had a history of hypertension and dyslipidemia as well as a family history of thoracic aortic dissection presented to a community hospital complaining of sudden onset of chest discomfort and dyspnea. He was diaphoretic, with blood pressure of 114/60mmHg and no pulse deficit, heart rate of 114 beats per minute and respiratory rate of 20 breaths per minute. In addition, he required oxygen by nasal cannula to maintain oxygen saturation above 90%. He had a large-volume central pulse, no extra heart sounds and soft systolic and early diastolic murmurs over the aortic valve. His jugular venous pressure was 4cm above the sternal angle, and he had crackles at both lung bases. There were no features suggestive of Marfan syndrome or connective tissue diseases. The initial emergency work-up included an electrocardiogram (EKG), which showed left ventricular hypertrophy with repolarization abnormalities; a chest X-ray with increased interstitial markings suggesting acute pulmonary edema; a troponin I level of 0.41μg/L; and a brain natriuretic peptide level of 487ng/L.\nOn the basis of the patient’s abrupt onset of symptoms, family history of aortic dissection and findings consistent with acute aortic insufficiency (large-volume pulse, early diastolic murmur and heart failure), an emergent contrast-enhanced CT scan was obtained . This scan showed a 5cm aortic root aneurysm but no aortic dissection. The patient was treated medically for acute coronary syndrome and heart failure, including dual anti-platelet therapy and anti-coagulation. He was subsequently transferred to a tertiary care hospital. Because of the high clinical suspicion of an acute aortic dissection based on his family history, sudden onset chest discomfort and findings of acute aortic insufficiency and heart failure , a transesophageal echocardiogram was taken, even in light of the negative CT scan . This test demonstrated an aortic dissection flap confined to the aortic root, superior to the aortic valve and associated with severe aortic insufficiency. The patient underwent successful repair of his Stanford type A aortic dissection with a 27mm mechanical valved conduit 21 hours after his initial presentation to the community hospital. The pathology report showed a structurally normal trileaflet native valve and cystic medial necrosis of the wall of the aortic root. Specialist cardiovascular radiologists who reviewed the initial CT scan post hoc reprocessed the raw data and correctly identified the dissection above the aortic valve . The dissection flap had initially been misinterpreted as a combination of normal aortic valve apparatus and motion artefact.", "summary": "We report the case of a 57-year-old Caucasian man with a typical presentation for acute type A aortic dissection in whom the initial non-cardiac gated computed tomographic angiogram was negative, leading to a delay in surgical management. Transesophageal echocardiography and post hoc 3D reconstruction of the original computed tomographic scan revealed a dissection flap confined to the aortic root, immediately superior to the sinuses of Valsalva and masquerading as part of the aortic valve apparatus.", "subclaim_evaluations": [ { "subclaim": "The patient was a 57-year-old man.", "support_label": "supported" }, { "subclaim": "The patient was Caucasian.", "support_label": "supported" }, { "subclaim": "The patient had acute type A aortic dissection.", "support_label": "supported" }, { "subclaim": "The initial non-cardiac gated computed tomographic angiogram was negative.", "support_label": "not_supported" }, { "subclaim": "Transesophageal echocardiography revealed a dissection flap.", "support_label": "supported" }, { "subclaim": "Post hoc 3D reconstruction of the original computed tomographic scan revealed a dissection flap.", "support_label": "supported" }, { "subclaim": "The dissection flap was confined to the aortic root.", "support_label": "supported" }, { "subclaim": "The dissection flap was immediately superior to the sinuses of Valsalva.", "support_label": "supported" }, { "subclaim": "The dissection flap masqueraded as part of the aortic valve apparatus.", "support_label": "supported" } ] }, { "id": "multiclinsum_test_57_en.txt", "fulltext": "A 73-year-old female complained of back pain and weakness in lower limbs for 2 weeks. 3 months ago, after a minor trauma, she got back pain without weakness in lower limbs. Radiography including lateral radiographs and MRI performed at a local hospital. Initially, she was diagnosed with a L1 compression fracture and accepted conservative treatment. After an asymptomatic period, she complained progressive pain at the fracture position with weakness of both lower limbs and was referred to our hospital with suspicion of Kümmell’s disease. The back pain evaluated by visual analog scale (VAS) scale was 9. According to American Spinal Injury Association (ASIA) grading criteria, the neurological function was rated as ASIA C. Sagittal MR images showed a fluid-containing IVC with high-signal intensity on T2-weighted images and STIR MR sequences at L1 and sagittal reconstruction CT scan showed a linear radiolucent IVC, accompanying spinal cord compression. The biochemical workup revealed no abnormal indications of infection (including C-reactive protein (CRP) levels, erythrocyte sedimentation rate (ESR) and T-SPOT). Furthermore, the patient denied the history of cancer or tuberculosis and she also denied hypothermia, night sweats and weakness.\nBefore surgery, we obtained the informed consent of the patient and her family to perform the operation. The patients were placed in a prone position under general anesthesia with somatosensory-evoked potentials and motor-evoked potentials for spinal cord monitoring. After the lesion was positioned with the C-arm, a standard posterior midline approach with subperiosteal stripping was used to expose the spinous processes, lamina, and facet joints. Considering the presence of osteoporosis in elder female patient, we performed a long segment pedicle screw fixation (Cox Spinal Screw-Rod System, Fule Science & Technology, Beijing, China) from T10-L3 to avoid implant failure . Then, a complete laminectomy-facetectomy was performed to decompress and fully visualize the dural sac. A temporary stabilizing rod was fixed on one side of the pedicle screws. On the contralateral side, the facet joints of the diseased vertebra were removed to reveal the pedicle. Then, the pedicle and vertebral body, including the superior and inferior disk, were piecemeal removed by rongeurs, osteotomes, or curettes. To our surprise, caseous necrosis and inflammatory granulation could be seen in the surgically resected lesions. The specimens were sent for pathologic examination. After osteotomy and debridement in anterior column at L1, we used a ‘off-the-shelf’ (OTS) three-dimensional (3D) printed artificial vertebral body instead of various materials, such as bone grafts, mesh cages, or expandable titanium cages, to reconstruct sagittal alignment . Based on preoperative 3D reconstruction of CT and MRI images, the artificial prosthesis was designed in conformity with the expected defects that may occur after the affected vertebral body resection.\nPathological examinations reported caseous necrosis tissue, epithelioid granuloma existed with the hyperplasia tissue and the acid-fast bacillus was also found .\nAfter surgery, the patient was treated with quadruple anti-tuberculous chemotherapy and hepatoprotective drug for 12 months and required to wear a brace for at least 3 months. Two weeks after surgery, the patient could walk and discharge from the hospital. Three months after surgery, the VAS scores decreased from preoperative 9 to 1 and the neurological function recovered to ASIA E. No internal fixation failure and recurrence of tuberculosis occur at last follow-up .", "summary": "A 73-year-old female complained of back pain and weakness in lower limbs for 2 weeks. 3 months ago, after a minor trauma, she got back pain without weakness in lower limbs. Initially, she was diagnosed with a L1 compression fracture and accepted conservative treatment. After an asymptomatic period, she complained progressive pain at the fracture position with weakness of both lower limbs and was referred to our hospital with suspicion of Kümmell's disease. The patient underwent posterior debridement and internal fixation for decompression and stabilization of the spine. Pathological examinations revealed the patient with spinal tuberculosis.", "subclaim_evaluations": [ { "subclaim": "The patient is a 73-year-old female.", "support_label": "supported" }, { "subclaim": "She complained of back pain.", "support_label": "supported" }, { "subclaim": "She had weakness in lower limbs.", "support_label": "supported" }, { "subclaim": "The symptoms lasted for 2 weeks.", "support_label": "supported" }, { "subclaim": "Three months ago, she had back pain after a minor trauma.", "support_label": "supported" }, { "subclaim": "At that time, she did not have weakness in lower limbs.", "support_label": "supported" }, { "subclaim": "She was diagnosed with a L1 compression fracture.", "support_label": "supported" }, { "subclaim": "She received conservative treatment.", "support_label": "supported" }, { "subclaim": "She had an asymptomatic period.", "support_label": "supported" }, { "subclaim": "She then had progressive pain at the fracture position.", "support_label": "supported" }, { "subclaim": "She had weakness of both lower limbs.", "support_label": "supported" }, { "subclaim": "She was referred to the hospital with suspicion of Kümmell's disease.", "support_label": "supported" }, { "subclaim": "She underwent posterior debridement.", "support_label": "supported" }, { "subclaim": "She underwent internal fixation.", "support_label": "supported" }, { "subclaim": "The procedure was for decompression and stabilization of the spine.", "support_label": "supported" }, { "subclaim": "Pathological examinations revealed spinal tuberculosis.", "support_label": "supported" } ] }, { "id": "multiclinsum_test_1167_en.txt", "fulltext": "A 74-year-old male was admitted to our hospital for the treatment of esophageal cancer. The patient had no symptoms with normal temperature at the time of admission. His past medical history included diabetes mellitus for 24 years. He underwent endoscopic submucosal dissection for early gastric cancer 4 years ago and video-assisted thoracic surgery for pulmonary adenocarcinoma in the right upper lobe 5 years ago. He occupation was making metal molds. He was ex-smoker: Brinkman index was 980. Laboratory studies showed white blood cells of 10.0 × 103/L, C-reactive protein of 6.07 mg/dL, hemoglobin A1c test of 8.8%, fasting blood sugar of 237 mg/dL on admission. Serum tumor markers, including CEA, CA19–9, SCC, CYFRA, were unremarkable. He underwent esophago-gastro-duodenoscopy for follow-up after endoscopic submucosal dissection for early gastric cancer. The upper endoscopy showed a 0-IIa lesion with relatively large granular nodules on the lower thoracic esophagus . The pathologic assessment of the biopsy revealed squamous cell carcinoma of the esophagus. The esophageal 0-IIa lesion with relatively large granular nodules let us consider the depth of esophageal cancer was deeper than M3/SM1. Chest X-Ray was normal, however, chest CT revealed a 1.3 cm × 0.9 cm pulmonary mass in the lower lobe of the right lung a month before admission . PET/CT showed the pulmonary mass had maximal standardized uptake value (SUVmax) of 3.88 (arrow) and part of the lower thoracic esophagus had SUVmax of 2.37 (arrowhead) 2 weeks before admission . Because the image of pulmonary mass had not changed between CT and PET/CT for 2 weeks and because he had no fever, even though he had inflammation reaction on laboratory studies, pulmonary mass was considered to be unlikely due to infection. Thus, he was initially diagnosed with esophageal cancer with a pulmonary metastasis or recurrence of a pulmonary adenocarcinoma. Considering the both possibilities, we started chemotherapy with cisplatin (CDDP) 70 mg/m2 day1 plus 5-fluorouracil (5-FU) 700 mg/m2 day1–4 on the day 4 after admission. On the day 8, CT revealed a slight pleural effusion in the right side . On the day 9, to rule out carcinomatous pleurisy, an ultrasound-guided aspiration of pleural effusion was performed. The effusion was serous and contained no malignant cells. After the aspiration, the patient got a high fever. Laboratory test showed white blood cells of 18.6 × 103/L (90.8% of Neutrophil), CRP of 25.87 mg/dL. Considering that fever was due to respiratory infection after the aspiration, intravenous Sulbactam/Ampicillin (6 g/day) was administered. On the day14, his fever was persistent and he also had a cough. Because CT revealed an increased amount of pleural effusion , we considered the mass was lung abscess. By the second ultrasound-guided aspiration of the pleural effusion, we got a 50 ml of white suppurative effusion. The effusion turned out to contain Actinomyces israelii , and proved pulmonary mass-like lesion was pulmonary actinomycosis. The patient received intravenous penicillin G (24 million units/day) for 4 weeks, followed by oral amoxicillin 2250 mg/day for 6 months. The patient received four courses of chemotherapy (CDDP/5-FU) and curative radiotherapy (1.8Gy/total 50.4Gy) as esophageal cancer deeper than M3/SM1. The pulmonary actinomycosis disappeared six months after the treatment with antibiotics . After the chemoradiation therapy without any complications, the esophageal cancer was in complete remission.", "summary": "A 74-year-old male who had esophageal cancer and a pulmonary mass that was positive for 18F-fluorodeoxyglucose positron emission tomography/computed tomography was initially diagnosed with esophageal cancer with a lung metastasis because he was asymptomatic. However, aspiration of pleural effusion revealed that the pulmonary lesion was actinomycosis.", "subclaim_evaluations": [ { "subclaim": "The patient is a 74-year-old male.", "support_label": "supported" }, { "subclaim": "The patient had esophageal cancer.", "support_label": "supported" }, { "subclaim": "The patient had a pulmonary mass.", "support_label": "supported" }, { "subclaim": "The pulmonary mass was positive for 18F-fluorodeoxyglucose positron emission tomography/computed tomography.", "support_label": "supported" }, { "subclaim": "The patient was initially diagnosed with esophageal cancer with a lung metastasis.", "support_label": "supported" }, { "subclaim": "The patient was asymptomatic.", "support_label": "supported" }, { "subclaim": "Aspiration of pleural effusion was performed.", "support_label": "supported" }, { "subclaim": "The pulmonary lesion was actinomycosis.", "support_label": "supported" } ] }, { "id": "multiclinsum_test_1851_en.txt", "fulltext": "A 51-year-old female patient with a 27-year history of bipolar disorder was admitted to the psychiatric clinic in September 2017 due to depressed mood, ideas of reference, delusions of persecution and anxiety. It was known from her medical history that her first psychotic episode (acute paranoid syndrome) occurred in 1990. The patient was hospitalized for a few weeks and was treated with antipsychotic drug (perazine) with a good result. Within the next 10 years the patient was hospitalized 4 times and diagnosed with depression and mania. The depressive episodes were treated with different antidepressant drugs (imipramine, perazine and venlafaxine) in combination with mood stabilizers (carbamazepine and/or lithium), whereas antipsychotic drugs were used to treat the mania. After the last hospitalization (in 2000) for depression, the patient continued her treatment (imipramine, perazine, lithium and carbamazepine) as an out-patient until 2008. The treatment of the patient was modified due to fluctuations in her mental state. Imipramine and carbamazepine were withdrawn and fluoxetine was commenced. In 2015, the patient was hospitalized owning to acute intoxication with lithium (> 1.2 mmol/l), renal failure and extrapyramidal symptoms. Lithium was withdrawn and gabapentine was initiated for the extrapyramidal symptoms. In addition, hypothyroidism was diagnosed and levothyroxine was prescribed, which patient took until 2016. Within the next 2 years the patient was taking fluoxetine (60 mg/d), perazine (150 mg/d) and gabapentine (800 mg/d). During that time carbamazepine was commenced (200 mg/d, max. to 800 mg/d) to stabilize the patient’s mood, but owing to severe deterioration of her mental state (intensification of both psychotic and depressive symptoms), the drug was withdrawn and lithium (max.1000 mg/d) was reintroduced. Additionally, olanzapine (5 mg/d) for psychotic symptoms and biperiden (4 mg/d) for muscle stiffness were added. Throughout the disease (since the first psychotic episode in 1990 until the last hospitalization in 2017), there were no psychiatric comorbidities diagnosed. Periodic hypothyroidism (in 2015) treated with levothyroxine and renal failure caused by acute intoxication with lithium were notable for the patient’s history.\nThe patient was admitted to the psychiatric clinic in September 2017 due to depressed mood, ideas of reference, delusions of persecution and anxiety. During her admission disturbances of consciousness were not observed and the patient was auto- and allopsychically orientated. The patient’s general condition was good (blood pressure: 115/70 mmHg, pulse 72, respiratory rate16/min and BMI 27,22). A regular systolic murmur was noted and lungs were clear bilaterally. The abdomen was symmetrical without distention and bowel sounds were normal in quality and intensity in all areas. The patient had dry skin and varicose veins of the lower extremities. Her laboratory results showed lithium levels of 1.48 mmol/l, GFR 35 ml/min, creatinine 1.56 mg/dl and WBC 10.42 × 10^3/ml. A urinary tract infection was diagnosed (leukocytosis 10.2 × 10^3/ml, positive result of urine inoculation-Klebsiella oxytoca) and antibiotic therapy was initiated (sulfamethoxazole with trimethoprim). After 5 days of treatment her physical state deteriorated, she developed a fever of 38.4 °C and her laboratory results revealed a toxic level of lithium carbonate 2.34 mmol/l, creatinine 2.05 mg/dl and GFR 25 ml/min. Acute renal failure was diagnosed by a nephrologist and as a result the lithium was withdrawn and the antibiotic therapy was replaced with ceftriaxone 2 g/d (lower nephrotoxicity). Normal saline was administered to the patient for two days in order to decrease the toxic level of lithium. The patient’s general condition and laboratory findings improved (level of lithium 1.34 mmol/l, creatinine 1.94 mg/l, GFR 27 ml/min), and 7 days later the antibiotic therapy was discontinued. Other laboratory results (biochemistry, hematology, lipidemia, ions and hormone levels- TSH, fT3, fT4) were found to be within normal range, so other somatic disorders, apart from renal failure, were excluded.\nAfter stabilization of her somatic condition, and despite her treatment (the patient was continuing treatment with fluoxetine 60 mg/d, olanzapine 5 mg/d, gabapentin 800 mg/d, perazine 150 mg/d and biperiden 4 mg/d), the patient’s mental state deteriorated significantly (depressed mood, ideas of reference, aggravated delusions of persecution), so the treatment was changed accordingly. All drugs taken by the patient so far were gradually withdrawn (olanzapine and perazine over 6 days; fluoxetine over 4 weeks, gabapentine over 3 weeks and biperiden over 1 week) and lamotrigine (200 mg/d) and aripiprazole (30 mg/d) were initiated. Lamotrigine was used to replace lithium, as it is a good mood stabilizer without any nephrotoxic influence on the kidneys. Lamotrigine was commenced at a dose of 25 mg/d, which the patient took for 2 weeks. The dosage was then increased to 50 mg/d for a week, and then incrementally increased each week up to the final dose of 200 mg/d. Aripiprazole was initiated at a dose of 7.5 mg/d in order to reduce delusions and was uptitrated to the final dose of 30 mg/d over 2 weeks. As a result of the insufficient effectiveness of aripiprazole and lamotrigine treatment, which lasted 6 weeks, (ideas of reference, delusions of persecutions were maintained and problems with sleep), quetiapine was added (50 mg/d) in the 6th week. A partial good response to the treatment was observed after 7 days (partial reduction of delusions and mood stabilization), so the doctors decided to uptitrate the quetiapine dose to 400 mg/d, which took 9 days. Further treatment with aripirazole, lamotrigine and quetiapine resulted in NMS development. A description of NMS and its treatment is presented in Table .\nTo assess and quantify the causal role of antipsychotic drugs in the mediation of NMS, the Adverse Drug Reaction (ADR) Probability Scale was used. According to this scale each drug was assigned to a probability category on the basis of points, which were calculated as follows: aripiprazole 2, lamotrigine 3 and quetiapine 5. Number of points: > 9 means definitive adverse drug reaction; 5 to 8 points- probable adverse drug reaction; 1 to 4- possible adverse drug reaction and 0- doubtful adverse drug reaction .", "summary": "A 51-year-old female patient with a 27-year history of bipolar disorder, being treated with lithium, fluoxetine, olanzapine, gabapentine, perazine and biperiden, was admitted to the hospital due to depressed mood and delusions. A urinary tract infection was diagnosed and antibiotic therapy was initiated. After 5 days of treatment her physical state deteriorated and she developed a fever of 38.4 °C. Her laboratory results revealed a toxic level of lithium (2.34 mmol/l). Acute renal failure was diagnosed and the lithium was withdrawn. After stabilization of her condition, and despite her antipsychotic treatment, further intensification of delusions and depressed mood were observed. All drugs being taken by the patient were withdrawn and lamotrigine and aripiprazole were initiated. Due to the insufficient effectiveness of aripiprazole treatment and because of problems with sleep, quetiapine was added, however further treatment with this drug combination and an increase of quetiapine to 400 mg/d eventually caused NMS. Amantadine, lorazepam and bromocriptine were therefore initiated and the patient's condition improved.", "subclaim_evaluations": [ { "subclaim": "The patient is a 51-year-old female.", "support_label": "supported" }, { "subclaim": "The patient has a 27-year history of bipolar disorder.", "support_label": "supported" }, { "subclaim": "The patient was being treated with lithium.", "support_label": "supported" }, { "subclaim": "The patient was being treated with fluoxetine.", "support_label": "supported" }, { "subclaim": "The patient was being treated with olanzapine.", "support_label": "supported" }, { "subclaim": "The patient was being treated with gabapentine.", "support_label": "supported" }, { "subclaim": "The patient was being treated with perazine.", "support_label": "supported" }, { "subclaim": "The patient was being treated with biperiden.", "support_label": "supported" }, { "subclaim": "The patient was admitted to the hospital due to depressed mood.", "support_label": "supported" }, { "subclaim": "The patient was admitted to the hospital due to delusions.", "support_label": "supported" }, { "subclaim": "A urinary tract infection was diagnosed.", "support_label": "supported" }, { "subclaim": "Antibiotic therapy was initiated.", "support_label": "supported" }, { "subclaim": "After 5 days of treatment, the patient's physical state deteriorated.", "support_label": "supported" }, { "subclaim": "The patient developed a fever of 38.4 °C.", "support_label": "supported" }, { "subclaim": "The lithium level was 2.34 mmol/l.", "support_label": "supported" }, { "subclaim": "Acute renal failure was diagnosed.", "support_label": "supported" }, { "subclaim": "Lithium was withdrawn.", "support_label": "supported" }, { "subclaim": "All drugs being taken by the patient were withdrawn.", "support_label": "supported" }, { "subclaim": "Lamotrigine was initiated.", "support_label": "supported" }, { "subclaim": "Aripiprazole was initiated.", "support_label": "supported" }, { "subclaim": "Quetiapine was added.", "support_label": "supported" }, { "subclaim": "Quetiapine was increased to 400 mg/d.", "support_label": "supported" }, { "subclaim": "NMS occurred.", "support_label": "supported" }, { "subclaim": "Amantadine was initiated.", "support_label": "not_supported" }, { "subclaim": "Lorazepam was initiated.", "support_label": "not_supported" }, { "subclaim": "Bromocriptine was initiated.", "support_label": "not_supported" }, { "subclaim": "The patient's condition improved.", "support_label": "not_supported" } ] }, { "id": "multiclinsum_test_2197_en.txt", "fulltext": "We report a case of a 54-year-old woman who presented with a new mass on the abdominal wall scar that had grown in the past 3 months. She had a cesarean sections 31 years ago. In 2017, she underwent laparoscopic right adnexectomy for a chocolate cyst of the right ovary.\nAn increased abdominal mass was reported in our hospital, and physical examination revealed a subcutaneous solid tumor with a diameter of 3 cm around the scar of laparoscopic surgery on the right lower abdomen. Transabdominal ultrasound showed a cystic tumor in the subcutaneous adipose layer of the right lower abdomen . Trans-vaginal ultrasonography showed normal findings.Routine laboratory findings and tumor markers (AFP, CA125, HE4 and CEA) were normal, but serums CA-199 were elevated at 41.48U/m U/mL. The patient was excised under general anesthesia. During the intraoperative exploration of the fat layer, a 3 × 2 cm mass with hard texture could be reached. After the fat was cut open, a cystic mass could be seen, in which coffee-colored fluid flowed out a poorly differentiated endometrioid carcinoma . PAX-8, ER, KI-67 and CD10 were positive, while STATB2, GATA3, CDX-2 and PR were negative. Combined with the patient's history of laparoscopic surgery, ultrasound and pathological findings, it was highly suspected that the tumor was a malignant transformation of laparoscopic trocar endometriosis.\nWhole-body positron emission tomography and computed tomography (18-FDG PET-CT) were performed at disease stage 14 days after surgery and showed slight hypermetabolism in the incision area. Multiple swollen lymph nodes in retrodiaphragmatic, retroperitoneal, bilateral iliac vessels and right inguinal area, abnormal metabolism.\nOur patient then underwent surgical staging, laparoscopy through the peritoneum. The abdominal and renal pelvis were carefully examined, intraoperative adhesions between the greater omentum, the abdominal wall and the fundus of the uterus were observed. Tumor nodules were observed on the surface of the sigmoid colon and rectum. Right total iliac, external iliac, internal iliac, obturator lymph nodes and para-aortic lymph nodes were enlarged and fused into masses. Final pathology revealed a metastatic poorly differentiated adenocarcinoma arising from a foci of endometriosis.Tumor metastasis was observed in right pelvic lymph node and right inguinal lymph node.The remainder of the specimens were negative for malignancy.\nSerum CA-125 and CA-199 increased to 36 one month after operation, 48 U/mL and 77.67U/mL, respectively. Serum CA-125 and CA-199 decreased to normal 4 months after surgery. After the operation, patients received systemic chemotherapy (6 cycles of tri-weekly liposomal doxorubicin 30 mg/m2 and carboplatin AUC = 5), which is similar to adjuvant chemotherapy for epithelial ovarian cancer. CT scans showed no evidence of recurrence after 6 cycles of chemotherapy. Three months after 6 times of chemotherapy, she underwent repeat 18-FDG PET-CT examination, which revealed most of the original enlarged lymph nodes disappeared, with only a few small lymph nodes behind the peritoneum and low metabolism.Our patients showed no signs of recurrence 16 months after initial diagnosis,CA199, AFP, CA125, HE4 and CEA were all normal.", "summary": "We report on a 54-year-old woman with trocar site endometriosis 2 years after laparoscopic ovarian endometrial resection. Physical examination revealed a subcutaneous solid tumor with a diameter of 3 cm surrounding the scar of laparoscopic surgery in the right lower abdomen. Transabdominal ultrasonography showed a cystic tumor in the subcutaneous adipose layer of the right lower abdomen. The pathological diagnosis was poorly differentiated endometrioid carcinoma. Hysterectomy, bilateral salpingo-oophorectomy and pelvic lymphadenectomy were then performed. Histological examination revealed mixed endometrioid carcinoma and clear cell carcinoma. After six cycles of chemotherapy, computed tomography showed no signs of recurrence.", "subclaim_evaluations": [ { "subclaim": "The patient is a 54-year-old woman.", "support_label": "supported" }, { "subclaim": "She had laparoscopic ovarian endometrial resection 2 years before the current presentation.", "support_label": "not_supported" }, { "subclaim": "She was diagnosed with trocar site endometriosis.", "support_label": "supported" }, { "subclaim": "Physical examination revealed a subcutaneous solid tumor with a diameter of 3 cm.", "support_label": "supported" }, { "subclaim": "The tumor was located around the scar of laparoscopic surgery in the right lower abdomen.", "support_label": "supported" }, { "subclaim": "Transabdominal ultrasonography showed a cystic tumor in the subcutaneous adipose layer of the right lower abdomen.", "support_label": "supported" }, { "subclaim": "The pathological diagnosis was poorly differentiated endometrioid carcinoma.", "support_label": "supported" }, { "subclaim": "Hysterectomy was performed.", "support_label": "not_supported" }, { "subclaim": "Bilateral salpingo-oophorectomy was performed.", "support_label": "not_supported" }, { "subclaim": "Pelvic lymphadenectomy was performed.", "support_label": "supported" }, { "subclaim": "Histological examination revealed mixed endometrioid carcinoma and clear cell carcinoma.", "support_label": "not_supported" }, { "subclaim": "The patient received six cycles of chemotherapy.", "support_label": "supported" }, { "subclaim": "Computed tomography showed no signs of recurrence after chemotherapy.", "support_label": "supported" } ] }, { "id": "multiclinsum_test_2044_en.txt", "fulltext": "A 57-year-old Asian man without relevant previous medical history was hospitalized following a fall from the 15th floor of a condominium. A witness said he had fallen from the condominium and had contacted electrical wires before hitting the ground. Prior to being transferred to the hospital, when the emergency medical service personnel arrived on scene, the patient had no pulse, but spontaneous circulation returned after 4 min of chest compression. On hospital arrival, the patient’s airway was maintained spontaneously, respiratory rate was 30 breaths/min, blood pressure was unmeasurable but the left femoral artery pulse was weakly palpable, heart rate was regular at 136 beats/min, body temperature was 36.1 °C, and Glasgow Coma Scale was E3V1M5. His right inner thigh was lacerated halfway around, and he was actively bleeding from this site. Blood analysis data on admission are shown in Table . We immediately initiated a massive transfusion protocol, secured the airway of the patient with endotracheal intubation and temporarily ligated the proximal exposed superficial femoral artery (SFA), deep femoral artery (DFA) just distal part after branching lateral femoral circumflex artery (LFCA), and superficial femoral vein separately. As we could not detect backflow from the distal artery, possibly because of intimal injury, spasm, or thrombus, and also as there was no time to expose this artery, we could not temporarily shunt it. As well, a tourniquet could not be applied because the injury site was too proximal to the torso. In parallel with preparations to initiate resuscitative endovascular balloon occlusion of the aorta via the left femoral artery, we packed the thigh and sequentially searched for other sites of bleeding because of the patient’s continued hemodynamic instability. Although we found no other sites of bleeding according to an extended focused assessment with sonography for trauma examination, subsequent plain pelvic radiography suggested the potential for retroperitoneal bleeding with iliac fracture. Considering the patient’s hemodynamics, we performed retroperitoneal packing by making suprapubic incision and entering preperitoneal space comprising the para-vesical and presacral space and then packing pads were placed.\nAfter this was completed, the patient was stable enough to undergo contrast-enhanced computed tomography (CECT). CECT showed fractures of the 4th lumbar vertebra and right iliac body concomitant with arterial extravasation at this site , so we performed transcatheter arterial embolization . Although CECT showed that the right SFA and DFA just distal part after branching LFCA were interrupted , narrow blood flow in the distal popliteal artery seemed to be maintained by collateral perfusion from LFCA as pulse doppler detected a weak pulse in the dorsal pedis artery. The ankle brachial pressure index at this time was approximately 0.54. After confirming good consciousness of the patient and resolving resuscitation-related conditions such as hypothermia and acidosis, we decided to perform revascularization of the femoral artery and vein by bypassing them with great saphenous vein grafts at approximately 24 h after the initial injury. The operation was performed with the patient in the supine position. Minor fresh thrombus was obtained from distal side of SFA and SFV by Fogarty catheter insertion and we could obtain sufficient back flow from both vessels. We decided to sacrifice the DFA and vein and bypass the SFA. The great saphenous vein was harvested from the left limb, and a graft of about 7 cm in length was anastomosed to the intact intima of the SFA . As the superficial femoral vein also appeared to be bypassable, we bypassed it with a great saphenous vein . All anastomoses were performed by use of 6-0 monofilament suture with the parachute technique.\nThe soft tissue was also severely injured with some loss of tissue apparent. We initially considered covering the anastomosed vessels with viable muscle, but as the tissue deficit was not completely uncoverable, negative pressure wound therapy was applied over the muscle tissue.\nThe patient was extubated on the 4th hospital day, and musculocutaneous grafting was performed 22 days after the initial operation following completion of negative pressure wound therapy. Postoperative CECT showed the patency of flow through the femoral vessels and the score of ABI improved 1.15. As adjuvant therapy, although we could not administrate anticoagulant drugs prior to surgery on the basis of concomitant injury, systemic unfractionated heparin infusion was used during and post 10 days after bypass surgery. And then we converted to oral administration of warfarin and controlled the international normalized ratio of prothrombin time at the range of 2.0–2.5.\nThe patient was transferred to a rehabilitation hospital 52 days after admission without any symptom such as swelling or intermittent claudication.", "summary": "A 57-year-old Asian man was transferred to hospital after having fallen from the 15th floor of a condominium. The patient was in cardiac arrest at the scene, but was successfully resuscitated by emergency medical services staff. On arrival, the patient's hemodynamics were completely collapsed with active external bleeding from the thigh, so we immediately started resuscitation including activation of massive transfusion protocol and temporarily ligated the transected proximal superficial femoral artery, deep femoral artery just distal after branching lateral femoral circumflex artery and the superficial femoral vein. Following radiological findings showing a potential pelvic fracture with active bleeding, we also performed retroperitoneal packing in the resuscitation room and moved the patient to the angiography room for transcatheter arterial embolization. The patient's consciousness was preserved and perfusion of the injured limb was barely maintained after his hemodynamics were adequately stabilized. As we detected weak perfusion of the lower limb via a potential collateral flow from the lateral femoral circumflex artery branches from deep femoral artery by pulse doppler of the dorsal pedis artery, we decided to reconstruct superficial femoral artery and vein at 24 h after injury using great saphenous vein bypass grafts. The patient was transferred to a rehabilitation hospital with good neurological and limb outcome after hospitalization for 52 days.", "subclaim_evaluations": [ { "subclaim": "The patient was a 57-year-old Asian man.", "support_label": "supported" }, { "subclaim": "The patient was transferred to hospital after falling from the 15th floor.", "support_label": "supported" }, { "subclaim": "The patient was in cardiac arrest at the scene.", "support_label": "supported" }, { "subclaim": "Emergency medical services staff successfully resuscitated the patient.", "support_label": "supported" }, { "subclaim": "On arrival, the patient's hemodynamics were completely collapsed.", "support_label": "not_supported" }, { "subclaim": "The patient had active external bleeding from the thigh.", "support_label": "supported" }, { "subclaim": "Massive transfusion protocol was activated.", "support_label": "supported" }, { "subclaim": "The transected proximal superficial femoral artery was temporarily ligated.", "support_label": "supported" }, { "subclaim": "The deep femoral artery was ligated just distal after branching the lateral femoral circumflex artery.", "support_label": "supported" }, { "subclaim": "The superficial femoral vein was temporarily ligated.", "support_label": "supported" }, { "subclaim": "Radiological findings showed a potential pelvic fracture with active bleeding.", "support_label": "supported" }, { "subclaim": "Retroperitoneal packing was performed in the resuscitation room.", "support_label": "supported" }, { "subclaim": "The patient was moved to the angiography room for transcatheter arterial embolization.", "support_label": "supported" }, { "subclaim": "The patient's consciousness was preserved.", "support_label": "supported" }, { "subclaim": "Perfusion of the injured limb was barely maintained.", "support_label": "supported" }, { "subclaim": "Weak perfusion of the lower limb was detected via a potential collateral flow from the lateral femoral circumflex artery branches.", "support_label": "supported" }, { "subclaim": "The superficial femoral artery and vein were reconstructed at 24 hours after injury.", "support_label": "supported" }, { "subclaim": "Great saphenous vein bypass grafts were used for the reconstruction.", "support_label": "supported" }, { "subclaim": "The patient was transferred to a rehabilitation hospital.", "support_label": "supported" }, { "subclaim": "The patient had good neurological and limb outcome after hospitalization for 52 days.", "support_label": "supported" } ] }, { "id": "multiclinsum_test_1850_en.txt", "fulltext": "The patient was a 75-year-old woman who presented with severe bilateral leg edema and epigastralgia. There was no past history of chronic hepatitis or blood transfusion. Admission laboratory tests revealed an elevated serum aspartate aminotransferase level (48 U/L), mildly decreased serum albumin (3.6 g/dL), mildly decreased serum (74%), mildly elevated D-dimer (12.9 μg/mL), and mildly elevated fibrin degradation product (12.6 μg/mL). The tumor marker AFP was slightly elevated to 585 ng/mL. The Child-Pugh classification was A, and the indocyanine green retention rate at 15 min was 12%. CT scans showed a huge tumor, 21 cm in diameter, in the right liver and TT, 37 mm in diameter, in the right atrium . The TT was pedunculated, swung like a pendulum with the heartbeat, and reached the tricuspid valve on a transesophageal ultrasound video . The symptomatic patient had a risk of sudden death due to TT in the right atrium. Therefore, we explained the high surgical mortality rate to the patient and her family, and they decided to proceed with surgery.\nAt first, a partial sternotomy was made, and cardiopulmonary bypass (CPB) via the aorta, superior vena cava, and right femoral vein and electrical ventricular fibrillation were performed after intravenous injection of 25,000 units of heparin sodium. Although the TT in the right atrium was very soft and fragile, thrombectomy from the right atrium and inferior vena cava (IVC) was successful . After the removal of TT, the IVC was clamped with a tourniquet above the diaphragm and the right atrium was sutured with 5–0 Prolene. After DC defibrillation was carried out, CPB was stopped, the tourniquet on the IVC was released, and 100 mg protamine was administered for the neutralization of heparin. The open heart surgery time was 23 min, and the CPB time was 42 min. Next, a reverse T incision was made, and right hepatectomy by anterior approach and IVC tumor thrombectomy were performed. After ligation of the anterior and posterior Glissonean pedicles, the liver parenchyma was transected under the Pringle maneuver and IVC clamping below the liver. After the IVC and right hepatic vein were confirmed by anterior approach, the IVC was opened and a residual TT in the IVC was removed under total hepatic vascular exclusion (THVE) . Finally, the huge tumor was removed with the diaphragm without pulmonary embolism. The total operation time was 9 h, and the total blood loss was 8200 mL. The tumor was of the massive type macroscopically , and cancer cells showed moderately to poorly differentiated HCC with invasion to the portal vein, hepatic vein, and diaphragm. The patient’s postoperative course was uneventful, and she was discharged 14 days after surgery. She is still alive 14 months after surgery with recurrence in the lung.", "summary": "Tumor thrombectomy under cardiopulmonary bypass with heparin and electrical ventricular fibrillation prior to hepatectomy was successfully performed to prevent sudden cardiac arrest or pulmonary embolism in a 75-year-old woman with a huge HCC and TT in the right atrium. After the neutralization of heparin, right hepatectomy with tumor thrombectomy in the inferior vena cava was performed. The total operation time was 9 h, and the total blood loss was 8200 mL. The patient's postoperative course was uneventful, and she was discharged 14 days after surgery. One year after surgery, she is alive with HCC recurrence in the lung.", "subclaim_evaluations": [ { "subclaim": "The patient was a 75-year-old woman.", "support_label": "supported" }, { "subclaim": "She had a huge hepatocellular carcinoma.", "support_label": "supported" }, { "subclaim": "She had a tumor thrombus in the right atrium.", "support_label": "supported" }, { "subclaim": "Tumor thrombectomy was performed under cardiopulmonary bypass.", "support_label": "supported" }, { "subclaim": "Heparin was used during the procedure.", "support_label": "supported" }, { "subclaim": "Electrical ventricular fibrillation was used during the procedure.", "support_label": "supported" }, { "subclaim": "The procedure was performed prior to hepatectomy.", "support_label": "supported" }, { "subclaim": "The goal was to prevent sudden cardiac arrest.", "support_label": "supported" }, { "subclaim": "The goal was to prevent pulmonary embolism.", "support_label": "supported" }, { "subclaim": "Right hepatectomy was performed after heparin neutralization.", "support_label": "supported" }, { "subclaim": "Tumor thrombectomy in the inferior vena cava was performed.", "support_label": "supported" }, { "subclaim": "The total operation time was 9 hours.", "support_label": "supported" }, { "subclaim": "The total blood loss was 8200 mL.", "support_label": "supported" }, { "subclaim": "The patient was discharged 14 days after surgery.", "support_label": "supported" }, { "subclaim": "One year after surgery, she is alive.", "support_label": "supported" }, { "subclaim": "HCC recurrence in the lung was noted one year after surgery.", "support_label": "supported" } ] }, { "id": "multiclinsum_test_1992_en.txt", "fulltext": "A 26-year-old woman was admitted to the emergency department due to intense headache, chest discomfort, palpitations, and breathlessness, with 4 h of evolution.\nPhysical examination showed tachypnoea, tachycardia (145 b.p.m.), blood pressure of 158/95 mmHg, no fever, and oxygen saturation on room air of 92%. Cardiac auscultation was normal but pulmonary auscultation revealed bilaterally dispersed crackles. She was pale, with cold and clammy extremities and decreased capillary refill time but peripheral pulses were easily palpable.\nThe patient had a personal history of migraine and had been submitted to periodontal surgery on the previous day. She was medicated with amoxicillin/clavulanic acid and prednisolone. No relevant family history was reported.\nThe electrocardiogram (EKG) revealed sinus tachycardia, left axis deviation, V4–V6 ST-segment depression, maximum 2 mm at V5, and an inverted T wave in aVL .\nTransthoracic echocardiography showed severe LV systolic dysfunction with midbasal segments akinesia and hypercontractility of the apical segments (, , Video S1).\nThe patient underwent aortic computed tomography angiography that excluded an acute aortic syndrome, but identified signs of severe pulmonary oedema and two heterogeneous solid masses in both adrenal glands, the largest on the right adrenal gland, measuring 9.2 × 9.2 × 10.8 cm, suggestive of a bilateral pheochromocytoma .\nThe patient progressed with respiratory failure and shock signs with poor peripheral perfusion, oligoanuria, and arterial hyperlactacidemia (41 mg/dL; normal range≤ 18 mg/dL), despite her hypertensive profile (mean arterial pressure 110–120 mmHg). At this stage, she was submitted to mechanical ventilation. Due to the rapidly deteriorated clinical status, she was referred and transported to the closest hospital with extracorporeal membrane oxygenation (ECMO) capability for immediate mechanical circulatory support.\nThe patient remained with veno-arterial ECMO (VA-ECMO) support for 14 days and progressive recovery of LV dysfunction was observed, enabling the weaning of the VA-ECMO support from the 10th day, without use of inotropics. There were no significant changes on the EKG on the following 2 days, with regression of repolarization changes at follow-up. The peak troponin I level was 1.73 ng/mL (normal range ≤0.015 mg/dL), on the first day of hospitalization with a slow but progressive fall and subsequent normalization.\nUrinary catecholamines and metanephrines in 24-h urine were elevated . Alpha-blockade was started with phenoxybenzamine and subsequently beta-blockade with metoprolol.\nOn the 35th day of hospitalization, open bilateral adrenalectomy was performed, without complications, and she began supplementation with gluco and mineralocorticoids. Anatomopathological examination confirmed the diagnosis of bilateral pheochromocytomas. The patient was discharged on the 49th day of hospitalization with complete recovery of the left ventricular systolic function and preserved neurologic status.\nAfter discharge, the patient performed body scintigraphy with MIBG-123 that excluded pheochromocytoma metastases or synchronous tumours, but she was diagnosed with bilateral thyroid medullary carcinoma. Total thyroidectomy was performed and the diagnose of Type 2 multiple endocrine neoplasia (MEN) syndrome was established.", "summary": "We present a case of a young woman was admitted to the emergency department due to intense headache, chest discomfort, palpitations, and breathlessness. An ITS secondary to a pheochromocytoma crisis presenting with CS was diagnosed. The patient was managed with veno-arterial extracorporeal membrane oxygenation, until recovery of LV function. On the 35th day of hospitalization, open bilateral adrenalectomy was performed.", "subclaim_evaluations": [ { "subclaim": "The patient was a young woman.", "support_label": "supported" }, { "subclaim": "She was admitted to the emergency department.", "support_label": "supported" }, { "subclaim": "She had intense headache.", "support_label": "supported" }, { "subclaim": "She had chest discomfort.", "support_label": "supported" }, { "subclaim": "She had palpitations.", "support_label": "supported" }, { "subclaim": "She had breathlessness.", "support_label": "supported" }, { "subclaim": "An ITS secondary to a pheochromocytoma crisis was diagnosed.", "support_label": "supported" }, { "subclaim": "The presentation included CS.", "support_label": "supported" }, { "subclaim": "The patient was managed with veno-arterial extracorporeal membrane oxygenation.", "support_label": "supported" }, { "subclaim": "LV function recovered.", "support_label": "supported" }, { "subclaim": "Open bilateral adrenalectomy was performed.", "support_label": "supported" }, { "subclaim": "The adrenalectomy was performed on the 35th day of hospitalization.", "support_label": "supported" } ] }, { "id": "multiclinsum_test_251_en.txt", "fulltext": "A 33-year-old man without a previous medical or surgical history presented with chief complaints of abdominal pain and vomiting. Physical examination revealed tenderness in the lower abdomen. Laboratory data were unremarkable: C-reactive protein level, 0.16 mg/dL; white blood cell count, 9600 /μL; neutrophil count, 91.3%; and lymphocyte count, 5.4%. Ultrasonography and radiography revealed no findings that could cause abdominal pain. Contrast-enhanced computed tomography (CT) demonstrated a 45-mm-sized mass with partial calcification in the ileum , without any signs of invagination, obstruction, or volvulus. No other findings suggesting the cause of abdominal pain were observed on CT. The patient was diagnosed with an ileal tumor. After the examination, the patient’s condition improved spontaneously. Several weeks later, for detailed examination of the tumor, magnetic resonance imaging (MRI) was performed, which revealed a tumor with hypointense signal on both T1-weighted (T1WI) and T2-weighted images (T2WI), and isointense signal on gadolinium-enhanced T1WI . Based on these findings, the differential diagnoses were a gastrointestinal stromal tumor, chronic distending hematoma, leiomyoma, and CFT.\nLaparoscopic surgery was performed for the pathological diagnosis and treatment. Two 5-mm ports were placed through a vertical 4-cm skin incision in the umbilicus using EZ access and Lap Protector (Hakko Medical, Nagano, Japan). Intraoperatively, a white-colored tumor was found in the ileum, 100 cm from the terminal ileum . Careful observation of the entire abdominal cavity did not detect any other tumors, lymph node metastasis, or dissemination. After careful observation, the tumor was lead extracorporeally through the umbilical incision and a partial resection of the ileum was performed. Reconstruction was performed with a functional end-to-end anastomosis. Macroscopic findings revealed that the tumor was pedunculated and located on the antimesenteric side. Microscopic findings revealed that the tumor extended from the muscularis propria to the subserosa. A few spindle cells and infiltration of lymphoplasmacytic cells were observed with dense hyalinized collagen and interspersed calcification in the background . Immunohistochemical findings revealed negative or nearly negative results for CD34, c-kit, DOG-1, desmin, S100, anaplastic lymphoma kinase, vimentin and smooth muscle actin. Factor-XIIIa was positive. The MIB-1 labeling index was less than 1%. Over 40% of the plasma cells in the stroma were IgG4 positive. The tumor was eventually diagnosed as a CFT. The patient was discharged on postoperative day 7 without any complications. No recurrence has been observed in the 6 months since the surgery.", "summary": "A 33-year-old man presented with chief complaints of abdominal pain and vomiting. Computed tomography demonstrated a 45-mm-sized pelvic mass with partial calcification in the ileum. The patient was diagnosed with an ileal tumor, and partial resection of the ileum was performed using the single-port laparoscopic technique. Pathologic findings revealed hypocellular spindle cells with dense hyalinized collagen, interspersed calcification, and infiltration of lymphoplasmacytic cells. Immunohistochemical analysis showed that the factor XIIIa was positive and other tumor-specific markers were negative. Based on these findings, the tumor was finally diagnosed as a CFT.", "subclaim_evaluations": [ { "subclaim": "The patient is a 33-year-old man.", "support_label": "supported" }, { "subclaim": "The patient had abdominal pain.", "support_label": "supported" }, { "subclaim": "The patient had vomiting.", "support_label": "supported" }, { "subclaim": "Computed tomography showed a 45-mm-sized pelvic mass.", "support_label": "not_supported" }, { "subclaim": "The mass was located in the ileum.", "support_label": "supported" }, { "subclaim": "The mass had partial calcification.", "support_label": "supported" }, { "subclaim": "The patient was diagnosed with an ileal tumor.", "support_label": "supported" }, { "subclaim": "Partial resection of the ileum was performed.", "support_label": "supported" }, { "subclaim": "The resection was done using the single-port laparoscopic technique.", "support_label": "supported" }, { "subclaim": "Pathologic findings showed hypocellular spindle cells.", "support_label": "supported" }, { "subclaim": "Dense hyalinized collagen was present.", "support_label": "supported" }, { "subclaim": "Interspersed calcification was observed.", "support_label": "supported" }, { "subclaim": "Lymphoplasmacytic cell infiltration was noted.", "support_label": "supported" }, { "subclaim": "Immunohistochemical analysis showed factor XIIIa positivity.", "support_label": "supported" }, { "subclaim": "Other tumor-specific markers were negative.", "support_label": "supported" }, { "subclaim": "The tumor was diagnosed as a CFT.", "support_label": "supported" } ] }, { "id": "multiclinsum_test_2816_en.txt", "fulltext": "A 79 year old man was admitted at our emergency department due to exertion dyspnoea and swelling of the upper limbs, head and neck. Five years ago the patient had undergone elective replacement of the aortic valve with a prosthetic one (Carbomedics 23 mm) and a concomitant ascending aorta aneurysm replacement with a 28 mm synthetic graft. On admission the patient was dyspnoic with malaise. His blood pressure was normal (128/82 mmHg) and the oxygen saturation without oxygen supply was 92%. Pulses were irregular and increased in rate. ECG showed atrial fibrillation with fast ventricular response (135 to 145 beats/min). The physical examination documented cyanotic and swollen head and neck and distended jugular veins. Superior vena cava syndrome (SVCS) was clinically diagnosed. Laboratory data included a prolonged INR of 7 and Ht: 35.6%. Other elements of blood count and coagulation time were within physiologic values. Cardiac enzymes were negative. LDH was 620 IU/L. The rest of his biochemical profile was normal. Arterial blood gases showed mild respiratory acidosis (PH: 7.33) due to elevated PCO2: 48mmHg.\nChest x-rays was further confirmatory of the clinical diagnosis showing a widened mediastinum. However the contrast CT angiography of the chest was remarkable, revealing a large pseudoaneurysm of the ascending aorta with a maximum diameter of 13cm compressing the superior vena cava and an extensive collateral circulation .\nTransfusions with 2 units of fresh frozen plasma were enough to lower the INR to 1.8 and the patient was then transferred to the operating room. Femoro-femoral cannulation was undertaken in order to establish cardiopulmonary bypass and decrease the patient's temperature to down to 16°C to safely commence circulatory arrest. After the completion of cooling with collection of the patient's blood within the reservoir of the extracorporeal device, repeat sternotomy was performed through safe surgical means. Retrograde cardioplegia was installed. The pseudoaneurysm was incised and the thrombotic material was carefully removed. Two sites of major leakage originating from the anterior and posterior segment of the distal anastomosis were revealed. Suturing with 3/0 prolene, reinforced by teflon patches, was performed. Eventually extracorporeal circulation was recommenced, gradual rewarming was carried out and successful weaning from cardiopulmonary bypass was achieved.\nThe patient was extubated 6 hours later and he remained in the intensive care unit for 18 hours. His postoperative course was uneventful. Ten days following his admission the patient was discharged in good condition, presenting however atrial fibrillation with good rate control under Amiodarone treatment. Three months following his discharge he remains free of symptoms.", "summary": "We present the case of a large pseudoaneurysm of the ascending aorta, five years after primary surgery, with a significant compression of the right mediastinal venous system causing superior vena cava syndrome, detected at chest CT angiography. Perioperative findings showed two rush out points both coming from the distal aortic suture line which was performed five years ago. The patient underwent reoperation under circulatory arrest facilitating safe exploration and repair of the distal anastomotic leaks", "subclaim_evaluations": [ { "subclaim": "The patient had a large pseudoaneurysm of the ascending aorta.", "support_label": "supported" }, { "subclaim": "The pseudoaneurysm was five years after primary surgery.", "support_label": "supported" }, { "subclaim": "The pseudoaneurysm caused significant compression of the right mediastinal venous system.", "support_label": "supported" }, { "subclaim": "The compression caused superior vena cava syndrome.", "support_label": "supported" }, { "subclaim": "The condition was detected at chest CT angiography.", "support_label": "supported" }, { "subclaim": "Perioperative findings showed two rush out points.", "support_label": "supported" }, { "subclaim": "Both rush out points came from the distal aortic suture line.", "support_label": "supported" }, { "subclaim": "The distal aortic suture line was performed five years ago.", "support_label": "supported" }, { "subclaim": "The patient underwent reoperation under circulatory arrest.", "support_label": "supported" }, { "subclaim": "The reoperation facilitated safe exploration and repair of the distal anastomotic leaks.", "support_label": "supported" } ] }, { "id": "multiclinsum_test_2889_en.txt", "fulltext": "A 33-year-old Bangladeshi woman with hypertension and diabetes had initially presented to a different hospital with intermittent episodes of palpitations for 2 years, with documented electrocardiographic (ECG) evidence of AF during the episodes. She had previously been on oral propafenone, amiodarone, and metoprolol, at separate times, but continued to experience paroxysmal AF.\nShe had a 2-year history of hypertension that was well controlled with metoprolol 50 mg twice daily and ramipril 5 mg once daily. She had type 2 diabetes mellitus, diagnosed 3 years previously, that was well controlled with metformin 500 mg twice daily. There was no evidence of diabetic nephropathy or microalbuminuria. Furthermore, other etiologies of AF, such as thyrotoxicosis, were excluded by her thyroid profile, which comprised normal levels of TSH, free triiodothyronine, and free thyroxine. Ischemic heart disease was excluded by a CT coronary angiogram, which revealed normal epicardial coronary arteries.\nGiven the indication of drug-refractory AF, our patient had undergone EPS at a different hospital from which she had been discharged 24 hours after the procedure. The EPS has comprised right femoral venous catheterization followed by the insertion of three venous sheaths into her femoral vein.\nBecause an inducible arrhythmia could not be reproduced, her pulmonary vein (PV) potentials were mapped and complete PV isolation was planned. But, because there was difficulty in isolating some of the PVs along with an extended procedural time, the procedure was abandoned. A plan was made to identify all PVs more specifically using other imaging techniques such as magnetic resonance imaging (MRI), prior to attempting the procedure again.\nShe presented to our hospital 48 hours after the EPS with shortness of breath and chest heaviness, associated with palpitations and recurrent episodes of syncope. When queried, she confirmed that these symptoms were not like those she had previously experienced during her paroxysms of AF, and reiterated that they only developed after the EPS.\nShe had no prior history of thromboembolic events, long flights, prolonged immobilization, or oral contraceptive use, and she denied any family history of thrombophilia. There was no evidence of either hypertensive or diabetic nephropathy. A urine dipstick test was negative for protein. A thrombophilia work-up revealed normal levels for protein C and S, antinuclear antibody, and anticardiolipin antibody, thus eliminating other causes of hypercoagulability as possible etiologies of thrombosis.\nOn examination, she was hemodynamically stable and heart and lung auscultation was unremarkable. There was no unilateral leg swelling. An ECG showed T inversions in leads III, aVF, and V1–4. It also revealed mild tricuspid regurgitation and a pulmonary artery systolic pressure (PASP) of 50 mmHg. Her right ventricle (RV) was dilated, with diameters measuring 38 mm at the basal level and 40 mm at mid-level, with a longitudinal measurement of 90 mm on the apical 4 chamber view. Tricuspid annular plane systolic excursion (TAPSE) was measured at 12 mm. Her left atrium (LA) was of normal size and measured 33 mm. Qualitative assessment revealed that right atrium was larger than her LA. There was no evidence of left ventricular (LV) hypertrophy. Her LV ejection fraction (EF) was 65 % and there were no regional wall motion abnormalities of her LV. There was no evidence of thrombus in any of the cardiac chambers.\nA CT coronary and pulmonary angiogram revealed normal coronaries with filling defects in the descending branch of her left pulmonary artery extending into the segmental arteries, suggesting thrombus .\nSubsequently, a duplex ultrasound study of her lower limb venous system showed absent blood flow in her right external and common femoral veins, confirming acute DVT affecting her right ilio-femoral segment without signs of recanalization .\nGiven the sequence of events and their temporal relationship with the EPS, and in the absence of other risk factors for DVT, it was established that the acute DVT occurred as a consequence of the femoral vein catheterization and multiple venous sheaths inserted for EPS, subsequently leading to PE. She was treated with subcutaneous enoxaparin 60 mg twice daily for 5 days along with the administration of oral warfarin. She continued taking the warfarin for 6 months, with a target therapeutic international normalized ratio of 2.5–3. She was asymptomatic at follow-up at six months, and, due to the resolution of the DVT, oral anticoagulation was discontinued.", "summary": "A 33-year-old Bangladeshi woman with hypertension and diabetes had initially presented with recurrent episodes of paroxysmal atrial fibrillation that manifested as palpitations for 2 years. Her atrial fibrillation was drug-refractory and could not be attributed to a treatable etiology. She had undergone an electrophysiological study at a different hospital, where right femoral venous catheterization was performed followed by the insertion of three venous sheaths. However, tachyarrhythmia could not be induced and a procedure to isolate the pulmonary vein was postponed because all the veins could not be isolated. Forty-eight hours later, she presented to our hospital with shortness of breath, chest heaviness, palpitations, and recurrent episodes of syncope. She had normal coronary arteries and no other risk factors for venous thromboembolism. She was hemodynamically stable on examination. There was echocardiographic evidence of pulmonary hypertension and right ventricular dilatation and dysfunction. A computed tomography pulmonary angiogram confirmed pulmonary embolus in the descending branch of her left pulmonary artery, extending up to the segmental arteries. Subsequently, a duplex ultrasound confirmed acute deep vein thrombosis affecting her right ilio-femoral segment. She was successfully managed with subcutaneous enoxaparin and oral warfarin (target international normalized ratio 2.5-3).", "subclaim_evaluations": [ { "subclaim": "The patient is a 33-year-old Bangladeshi woman.", "support_label": "supported" }, { "subclaim": "She has hypertension.", "support_label": "supported" }, { "subclaim": "She has diabetes.", "support_label": "supported" }, { "subclaim": "She had recurrent episodes of paroxysmal atrial fibrillation.", "support_label": "supported" }, { "subclaim": "The atrial fibrillation manifested as palpitations for 2 years.", "support_label": "supported" }, { "subclaim": "The atrial fibrillation was drug-refractory.", "support_label": "supported" }, { "subclaim": "The atrial fibrillation could not be attributed to a treatable etiology.", "support_label": "supported" }, { "subclaim": "She had undergone an electrophysiological study at a different hospital.", "support_label": "supported" }, { "subclaim": "Right femoral venous catheterization was performed.", "support_label": "supported" }, { "subclaim": "Three venous sheaths were inserted.", "support_label": "supported" }, { "subclaim": "Tachyarrhythmia could not be induced.", "support_label": "supported" }, { "subclaim": "A procedure to isolate the pulmonary vein was postponed.", "support_label": "supported" }, { "subclaim": "All the veins could not be isolated.", "support_label": "supported" }, { "subclaim": "Forty-eight hours later, she presented with shortness of breath.", "support_label": "supported" }, { "subclaim": "She had chest heaviness.", "support_label": "supported" }, { "subclaim": "She had palpitations.", "support_label": "supported" }, { "subclaim": "She had recurrent episodes of syncope.", "support_label": "supported" }, { "subclaim": "She had normal coronary arteries.", "support_label": "supported" }, { "subclaim": "There were no other risk factors for venous thromboembolism.", "support_label": "supported" }, { "subclaim": "Echocardiography showed pulmonary hypertension.", "support_label": "supported" }, { "subclaim": "Echocardiography showed right ventricular dilatation.", "support_label": "supported" }, { "subclaim": "Echocardiography showed right ventricular dysfunction.", "support_label": "supported" }, { "subclaim": "A computed tomography pulmonary angiogram confirmed pulmonary embolus.", "support_label": "supported" }, { "subclaim": "The pulmonary embolus was in the descending branch of the left pulmonary artery.", "support_label": "supported" }, { "subclaim": "The pulmonary embolus extended up to the segmental arteries.", "support_label": "supported" }, { "subclaim": "A duplex ultrasound confirmed acute deep vein thrombosis.", "support_label": "supported" }, { "subclaim": "The deep vein thrombosis affected the right ilio-femoral segment.", "support_label": "supported" }, { "subclaim": "She was managed with subcutaneous enoxaparin.", "support_label": "supported" }, { "subclaim": "She was managed with oral warfarin.", "support_label": "supported" }, { "subclaim": "The target international normalized ratio was 2.5-3.", "support_label": "supported" } ] }, { "id": "multiclinsum_test_181_en.txt", "fulltext": "Our patient was 35 year old male who presented to emergency department with history of fall by tripping on a stone (fall on outstretched hand). Post trauma patient had pain and difficulty moving both the shoulders. Patient was a known alcoholic, with previous history of one episode of shoulder dislocation on right side about 2 years prior to the present episode, which was adequately treated with closed reduction and immobilisation for 3 weeks. Patient does not give any history of convulsions (past or present) and no other neuro-muscular problems. On clinical examination, patient's both upper limbs were abducted and externally rotated. Bilaterally shoulder contour was lost with flattening. Other classical signs of shoulder dislocation viz, Bryants test, Callway sign, Hamilton's ruler test were positive. Radiographs of both shoulders were obtained and clinical diagnosis of SBAD was confirmed. Both shoulders were reduced in emergency operation theater under general anaesthesia by Kocher's method and were immobilized in sling. The left was immobilized with 90° elbow flexion and the right at 110° flexion for 3 weeks. Reduction was confirmed post operatively with X-rays. Intermitted assisted excercises where started from second week onwards and at the end of immobilization patient was advised vigorous supervised physiotherapy. By six week post injury patient had full range of adduction, flexion and internal rotation. Abduction up to 110° was possible. Patient was advised to be cautious while doing overhead activities especially which require abduction and external rotation of shoulder.", "summary": "35 year old male presented to emergency department with history fall by tripping on a stone (fall on outstretched hand). He complained of pain and difficulty in moving both the shoulders. On clinical examination, patient's both upper limbs were abducted and externally rotated. Bilaterally shoulder contour was lost with flattening. Other classical signs of shoulder dislocation viz, Bryants test, Callway sign, Hamilton's ruler test were positive. Diagnosis was confirmed on X rays. Both shoulders were reduced in emergency operation theater under general anaesthesia by Kocher's method and were immobilised in sling.", "subclaim_evaluations": [ { "subclaim": "The patient is a 35 year old male.", "support_label": "supported" }, { "subclaim": "He presented to the emergency department.", "support_label": "supported" }, { "subclaim": "He had a history of a fall by tripping on a stone.", "support_label": "supported" }, { "subclaim": "The fall was on an outstretched hand.", "support_label": "supported" }, { "subclaim": "He complained of pain.", "support_label": "supported" }, { "subclaim": "He had difficulty moving both shoulders.", "support_label": "supported" }, { "subclaim": "On clinical examination, both upper limbs were abducted.", "support_label": "supported" }, { "subclaim": "On clinical examination, both upper limbs were externally rotated.", "support_label": "supported" }, { "subclaim": "Bilaterally, shoulder contour was lost.", "support_label": "supported" }, { "subclaim": "Bilaterally, there was flattening.", "support_label": "supported" }, { "subclaim": "Bryant's test was positive.", "support_label": "supported" }, { "subclaim": "Callaway sign was positive.", "support_label": "supported" }, { "subclaim": "Hamilton's ruler test was positive.", "support_label": "supported" }, { "subclaim": "Diagnosis was confirmed on X-rays.", "support_label": "supported" }, { "subclaim": "Both shoulders were reduced in the emergency operation theater.", "support_label": "supported" }, { "subclaim": "Reduction was performed under general anesthesia.", "support_label": "supported" }, { "subclaim": "Kocher's method was used for reduction.", "support_label": "supported" }, { "subclaim": "Both shoulders were immobilized in a sling.", "support_label": "supported" } ] }, { "id": "multiclinsum_test_2945_en.txt", "fulltext": "A 63-year-old male presented with dorsal pain of a 3 month duration. He had undergone gross-total resection of an invasive mixed AB thymoma (Masaoka-Koga II–III) 21 years ago, followed by local radiotherapy (52 Gy). After staying disease free for 12 years, he developed three pleural nodules; subsequent biopsy demonstrated pleural recurrent thymoma that was then treated with gamma knife radiosurgery (13 × 300 cGy in each lesion). The pleural lesions remained stable for the next 10 years. The patient was referred to our institution at the time radiographic spinal cord compression at T8-T9 level was discovered in addition to pleural thickening involving both hemithoraces . Examination did not evidence any neurological deficits.\nThe magnetic resonance imaging showed an irregular, dumbbell-shaped lesion at the T8–T9 level with an intraspinal component occupying 60% of the canal, displacing the cord toward the left .\nThe spinal and foraminal components of the tumor were removed through a one-level laminectomy with right-sided foraminotomy and medial T8–T9 facetectomy . The right T8 root was encased by an epidural solid tumor mass . Following gross total resection, a small dural hole was repaired at the right-sided T8 exiting nerve root . Intraoperatively, neurophysiologic recordings remained stable . The patient's postoperative course was uneventful. Postoperative MRI confirmed complete removal of the spinal tumor component . He declined postoperative adjuvant chemotherapy. Six months postoperatively, he remained neurologically intact without pain.\nThe histological analysis revealed an admixture of neoplastic epithelial cells and nonneoplastic small lymphocytes. The morphological and immunostaining features of the tumor corresponded to metastatic thymoma .", "summary": "A 63-year-old man, with a history of invasive type AB thymoma treated 21 years ago, newly presented to the hospital with a dumbbell-shaped T8-T9 lesion compressing the spinal cord. A review of the literature showed only 16 previous cases of thymic tumors with thoracic spine involvement. Here, we report the lengthiest interval between the initial tumor diagnosis and the detection of spinal involvement, that was secondary to a pleural recurrence from his thymoma. The patient did well following successful excision of the intraspinal mass which had encased the T8 nerve root.", "subclaim_evaluations": [ { "subclaim": "The patient is a 63-year-old man.", "support_label": "supported" }, { "subclaim": "He has a history of invasive type AB thymoma.", "support_label": "supported" }, { "subclaim": "The thymoma was treated 21 years ago.", "support_label": "supported" }, { "subclaim": "He presented with a dumbbell-shaped T8-T9 lesion.", "support_label": "supported" }, { "subclaim": "The lesion was compressing the spinal cord.", "support_label": "supported" }, { "subclaim": "A review of the literature found 16 previous cases of thymic tumors with thoracic spine involvement.", "support_label": "not_supported" }, { "subclaim": "This case had the longest interval between initial tumor diagnosis and spinal involvement.", "support_label": "not_supported" }, { "subclaim": "The spinal involvement was secondary to a pleural recurrence from his thymoma.", "support_label": "supported" }, { "subclaim": "The patient had successful excision of the intraspinal mass.", "support_label": "supported" }, { "subclaim": "The mass had encased the T8 nerve root.", "support_label": "supported" } ] }, { "id": "multiclinsum_test_235_en.txt", "fulltext": "In August 2008, a 44-year-old female had undergone surgery for resection of a malignant melanoma in the right lower leg and a right inguinal metastatic lymph node , followed by chemotherapy with doxorubicin, adriamycin, vincristine, and interferon beta (DAV-feron). In March 2012, computed tomography (CT) revealed brain and lung metastases, so the patient began radiation therapy to treat these lesions.\nIn September 2012, the patient was admitted to our hospital for back pain. Abdominal CT and magnetic resonance imaging detected new multiple hepatic metastases of melanoma. A transcatheter arterial infusion of cisplatin was administered, and transcatheter arterial embolization (TAE) was performed. In October 2012, she began treatment with vemurafenib, based on the finding of a positive BRAF V600E mutation in the resected primary site of the skin, which was analyzed by direct sequencing analysis using DNA from the paraffin-embedded primary cutaneous melanoma. She tolerated the treatment remarkably well, and the size of the multiple hepatic and lung metastases decreased, while the size of the brain metastases did not. In addition, the serum concentration of 5-S-cysteinyldopa (5-S-CD), a biological marker of melanoma progression, was also decreased from 40.1 ng/mL to 5.2 ng/mL.\nIn December 2012, she suddenly developed severe abdominal pain. Abdominal CT revealed ruptured hepatic metastases accompanied by massive intra-peritoneal hemorrhage. A retrospective and sequential analysis of the CT images suggested that a part of the liver metastases had enlarged rapidly and then ruptured with intratumoral hemorrhage during vemurafenib treatment . An emergency TAE was performed by selective occlusion of the right hepatic artery using gelatin sponge particles. The postoperative course was uneventful for several days. However, on the 26th postoperative day, she developed hemorrhagic shock and died of renewed intra-abdominal bleeding.\nAn autopsy examination revealed hemoperitoneum due to rupture of the liver metastases. Metastases were also discovered in the brain and lungs as well as in the kidneys, adrenal gland, and lymph nodes, although these had not been detected on imaging while she was alive. There was also massive bloody ascites (1700 mL). The background liver was completely normal, whereas exposed necrotic tissue and intratumoral hemorrhage were observed at the site of tumor rupture . We concluded that the cause of death was hemorrhagic shock from ruptured hepatic metastases of malignant melanoma. Finally, for improved understanding of the mechanism of refractory metastasis, we conducted an immunohistochemical analysis of the signal transduction molecules, phosphorylated extracellular signal-regulated kinase (p-ERK), and phosphorylated Akt (p-Akt), as well as the melanocyte marker Melan-A and Ki-67 in tumor cells of the primary malignant melanoma obtained from the right lower leg and in hepatic and lymph node metastases obtained on autopsy . Our findings showed that hepatic and lymph node metastases were positive for p-ERK and negative for p-AKT, even though the primary tumor was negative for both.", "summary": "A 44-year-old female had previously undergone surgery for resection of a malignant melanoma in the lower right leg. Four years later, hepatic metastases became apparent, and transcatheter arterial embolization (TAE) was performed. Then she underwent treatment with vemurafenib. The size of the hepatic metastases markedly decreased. Two months later, they enlarged rapidly and ruptured, requiring emergency TAE. However, the patient developed hemorrhagic shock and died of renewed intra-abdominal bleeding on the 26th postoperative day.", "subclaim_evaluations": [ { "subclaim": "The patient is a 44-year-old female.", "support_label": "supported" }, { "subclaim": "She had previously undergone surgery for resection of a malignant melanoma in the lower right leg.", "support_label": "supported" }, { "subclaim": "Four years later, hepatic metastases became apparent.", "support_label": "supported" }, { "subclaim": "Transcatheter arterial embolization (TAE) was performed.", "support_label": "supported" }, { "subclaim": "She underwent treatment with vemurafenib.", "support_label": "supported" }, { "subclaim": "The size of the hepatic metastases markedly decreased.", "support_label": "supported" }, { "subclaim": "Two months later, the hepatic metastases enlarged rapidly.", "support_label": "supported" }, { "subclaim": "The hepatic metastases ruptured.", "support_label": "supported" }, { "subclaim": "Emergency TAE was required.", "support_label": "supported" }, { "subclaim": "The patient developed hemorrhagic shock.", "support_label": "supported" }, { "subclaim": "The patient died of renewed intra-abdominal bleeding.", "support_label": "supported" }, { "subclaim": "The patient died on the 26th postoperative day.", "support_label": "supported" } ] }, { "id": "multiclinsum_test_1822_en.txt", "fulltext": "The patient, cmh000720, is currently a 6-year-old male who was referred for whole exome sequencing at 4 years of age. The patient was conceived via artificial insemination and was born at an estimated 38 weeks gestation via C-section to a 32-year-old G3P2 mother and distantly related 27-year-old father (5th cousins once removed). The pregnancy was complicated by gestational diabetes that was well managed with diet. Decreased fetal movements were noted throughout pregnancy, however the results from ultrasound exams and maternal serum AFP testing were normal. At birth the patient was noted to have a week cry, hypotonia, joint hypermobility, and an undescended testicle. Apgar scores were 8 and 9 at 1 and 5 min respectively; weight was 3.1 kg (30th%ile) and length 50.8 cm (68th%ile). He was discharged home at 2 days of life. Newborn screening was reported to be normal. At a routine pediatric follow up appointment at two weeks of age the patient was hospitalized for additional evaluation due to concerns of his persistent low tone and cardiac murmur. At that time he was noted to have both a left hip dislocation and right hip subluxation, with bilateral acetabular dysplasia. Use of a Pavlik harness failed correct the hip dislocation due to profound ligamentous laxity. Echocardiogram revealed a PFO and biscupid aortic valve. The patient had inconsistent TSH levels and thus was treated with levothyroxine. An MRI was suggestive of an arachnoid cyst, but was otherwise unremarkable. At 2.5 months of age an EEG revealed abnormal sharp waves, and CSF glucose levels were found to be 38. Due to a concern for a GLUT1 deficiency, a ketogenic diet was trialed but discontinued after the patient became lethargic on the diet and repeat testing was normal. The patient has had no documented clinical seizure activity.\nIn addition to his hip dysplasia, cmh000720 was also noted to have significant kyphoscoliosis and osteopenia by 4 months of age. He has had multiple fractures associated with little to no trauma including his left tibia (12 months), right femur (19 months), right tibia (20 months), left femur (2.5 years), right femur shaft (3.75 years), distal right femur (3.8 years), and left femur (4.2 years). Pamidronate infusions were trialed but an increase in fractures was noted. He has significant osteoporosis; bone density by dexa of the left forearm at 4 years of age was measured as Z score of -5.8. Spinal fusion rods were placed at 3 years of age and removed at 5 years of age. He is currently in a hard brace. Stabilization rods were also placed in both femurs .\nThe patient had developmental delay of gross motor milestones; currently he is able to walk with a walker and bear weight but cannot walk independently. Cognitively he is normal; he was able to say single words at 12 months and currently only has problems with articulation. At 6 years of age, in addition to the aforementioned symptoms, the patient is followed for mild aortic root and ascending aorta dilation, restrictive lung disease requiring C-PAP/BiPAP due to scoliosis and chronic obstructive pulmonary disease, bilateral hyperopia, astigmatism, amblyopia, and mild left ptosis, and hypoglycemia with illness. His weight 24.76 kg (85th%ile) and length 111 cm (13th%ile) are within normal limits, although he still receives supplemental nutrition overnight through a G-tube that was placed at 20 months of age. He is macrocephalic with an OFC of 54.8 cm (>98th%ile). He is only mildly dysmorphic with downslanting palpebral fissures, bluish/grey sclera, a high arched palate, short neck, arachnodactyly, and hyperextensible skin with no striae . His bone age is estimated at 4 years 6 months (>2 SD below expected for chronological age). He completed kindergarten with an IEP that includes occupational, speech and physical therapies.\nThe family history is notable for an older brother who was found to have a biscuspid aortic valve, after recommended screening. He has a healthy younger sister. Echocardiograms of both parents and younger sister were normal. Both parents are tall, and reportedly healthy.", "summary": "In this study, a 4-year-old patient with a severe phenotype of osteoporosis, hypotonia, joint laxity, fractures, scoliosis, biscuspid aortic valve and myopia was referred for next generation sequencing after extensive negative clinical testing. Whole exome sequencing was performed on the proband and his unaffected parents to identify the molecular basis of his disease. Sequencing revealed compound heterozygous variants in B3GAT3: c.1A > G (p.Met1?) and c.671 T > A (p.L224Q). Clinical and in vitro functional studies were then completed to verify the pathogenicity of the genotype and further characterize the functional basis of the patient's disease demonstrating the patient had a decrease both in the protein level of B3GAT3 and in the glucuronyltransferase activity when compared to control samples. Independent in vitro assessment of each variant confirmed the B3GAT3: c.1A > G (p.Met1?) variant is functionally null and the c.671 T > A (p.L224Q) missense variant has significantly reduced glucuronyltransferase activity (~3% of control).", "subclaim_evaluations": [ { "subclaim": "The patient is a 4-year-old.", "support_label": "not_supported" }, { "subclaim": "The patient has a severe phenotype of osteoporosis.", "support_label": "supported" }, { "subclaim": "The patient has hypotonia.", "support_label": "supported" }, { "subclaim": "The patient has joint laxity.", "support_label": "supported" }, { "subclaim": "The patient has fractures.", "support_label": "supported" }, { "subclaim": "The patient has scoliosis.", "support_label": "supported" }, { "subclaim": "The patient has a biscuspid aortic valve.", "support_label": "supported" }, { "subclaim": "The patient has myopia.", "support_label": "not_supported" }, { "subclaim": "The patient was referred for next generation sequencing.", "support_label": "supported" }, { "subclaim": "Extensive clinical testing was negative.", "support_label": "not_supported" }, { "subclaim": "Whole exome sequencing was performed on the proband.", "support_label": "supported" }, { "subclaim": "Whole exome sequencing was performed on the proband's unaffected parents.", "support_label": "not_supported" }, { "subclaim": "Compound heterozygous variants in B3GAT3 were identified.", "support_label": "not_supported" }, { "subclaim": "The variants are c.1A > G (p.Met1?) and c.671 T > A (p.L224Q).", "support_label": "not_supported" }, { "subclaim": "Clinical and in vitro functional studies were completed.", "support_label": "not_supported" }, { "subclaim": "The patient had decreased B3GAT3 protein levels compared to controls.", "support_label": "not_supported" }, { "subclaim": "The patient had decreased glucuronyltransferase activity compared to controls.", "support_label": "not_supported" }, { "subclaim": "Independent in vitro assessment of each variant was performed.", "support_label": "not_supported" }, { "subclaim": "The B3GAT3: c.1A > G (p.Met1?) variant is functionally null.", "support_label": "not_supported" }, { "subclaim": "The B3GAT3: c.671 T > A (p.L224Q) variant has significantly reduced glucuronyltransferase activity.", "support_label": "not_supported" }, { "subclaim": "The B3GAT3: c.671 T > A (p.L224Q) variant has ~3% of control glucuronyltransferase activity.", "support_label": "not_supported" } ] }, { "id": "multiclinsum_test_614_en.txt", "fulltext": "A 39-year-old, healthy, non-smoking female patient with no family history of cancer was referred on suspicion of rectal cancer. Digital rectal examination and subsequent rigid proctoscopy revealed a low rectal tumor and multiple polyps in the rectum. Subsequent colonoscopy showed extensive polyposis of the entire colon. The tumor biopsy confirmed the presence of a rectal adenocarcinoma, while dysplastic changes were found in the polyp biopsies. No distant metastases were detected on the thoracoabdominal computed tomography (CT) scan, and baseline carcinoembryonic antigen (CEA) was 8 μg/L. Pelvic magnetic resonance imaging (MRI) revealed a locally advanced rectal cancer with extra-mesorectal growth into the rectovaginal septum and the lower posterior vaginal wall as well as a suspected growth into the anterior aspect of the coccygeal bone with multiple suspected malignant lymph nodes within the mesorectum (T4N2). Upon evaluation by our multidisciplinary team (MDT), she was scheduled for neoadjuvant chemoradiotherapy (CRT) followed by surgery. Neoadjuvant treatment was given as CT planned radiotherapy (daily 2-Gy fractions, 5 days per week; the initial 23 fractions to the macroscopic tumor and areas at risk, and the two final fractions adapted to the macroscopic tumor) with concomitant capecitabine (825 mg/m2) on days of RT. The response evaluation showed excellent tumor volume response, but with similar organ involvement as at baseline, and she proceeded to surgery 8 weeks after CRT completion. Surgery involved total colectomy, APE with resection of the posterior vaginal wall and coccygeal bone with subsequent reconstruction of the perineum with right-sided VRAM flap, and a terminal ileostomy. After an uneventful recovery, she was discharged 15 days postoperatively. Histologic examination of the specimen showed a 35-mm large adenosquamous carcinoma removed with free resection margins and metastasis in one of four local lymph nodes (pT2N1). In addition, multiple dysplastic adenomas were present in the entire colon.\nAt the routine follow-up 6 months postoperatively, clinical examination revealed a 2 × 2 cm tumor located in the muscle tissue of the VRAM flap, and an early local recurrence was suspected. Pelvic MRI showed a 10 × 16 mm rich vascularized and cell dense lesion corresponding to the clinically detected tumor . No other pathological findings were made on CT or MRI, and CEA was 1 μg/L. The lesion was surgically excised with a wide local resection of the tumor. Interestingly, histologic examination of the removed lesion described a mass composed of fatty tissue, fibrocytes, and fibroblasts arranged in broad, sweeping fascicles infiltrating the adjacent striated muscle tissue. No dysplasia was observed, but mitoses were present. Immunohistochemistry showed positive staining for β-catenin (ABCAM, Cambridge, USA), and the tumor was diagnosed as a fibromatosis . The medical geneticists suspected familial adenomatous polyposis (FAP), and testing of the APC gene, revealed a known disease-causing mutation c.3317dupG (p.Ala1107Serfs*12), confirming this diagnosis.", "summary": "A 39-year-old female patient with low rectal cancer and extensive colorectal polyposis was treated with neoadjuvant chemoradiotherapy followed by colectomy and abdominoperineal excision with resection of the dorsal vaginal wall and subsequent reconstruction of the perineum using the vertical rectus abdominis myocutaneous flap. At the 6-month follow-up, a suspected 2 × 2 cm tumor recurrence was detected in the transposed tissue and was subsequently surgically removed. Histologic examination concluded with fibromatosis. Genetic testing revealed a known disease-causing mutation in the adenomatous polyposis coli gene, confirming the diagnosis of familial adenomatous polyposis.", "subclaim_evaluations": [ { "subclaim": "The patient is a 39-year-old female.", "support_label": "supported" }, { "subclaim": "The patient had low rectal cancer.", "support_label": "supported" }, { "subclaim": "The patient had extensive colorectal polyposis.", "support_label": "supported" }, { "subclaim": "The patient received neoadjuvant chemoradiotherapy.", "support_label": "supported" }, { "subclaim": "The patient underwent colectomy.", "support_label": "supported" }, { "subclaim": "The patient underwent abdominoperineal excision.", "support_label": "supported" }, { "subclaim": "The patient had resection of the dorsal vaginal wall.", "support_label": "supported" }, { "subclaim": "The patient had perineal reconstruction using the vertical rectus abdominis myocutaneous flap.", "support_label": "supported" }, { "subclaim": "At 6 months post-surgery, a 2 × 2 cm tumor recurrence was suspected in the transposed tissue.", "support_label": "supported" }, { "subclaim": "The suspected tumor recurrence was surgically removed.", "support_label": "supported" }, { "subclaim": "Histologic examination of the removed tissue concluded with fibromatosis.", "support_label": "supported" }, { "subclaim": "Genetic testing revealed a known disease-causing mutation in the adenomatous polyposis coli gene.", "support_label": "supported" }, { "subclaim": "The diagnosis of familial adenomatous polyposis was confirmed.", "support_label": "supported" } ] }, { "id": "multiclinsum_test_746_en.txt", "fulltext": "A 26-year-old male presented with severe dyspnea, palpitation, orthopnea, and paroxysmal nocturnal dyspnea. He had hypertension, medical history of ischemic stroke 5 months ago, and repeated hospitalization caused by congestive heart failure. His blood pressure in the right arm was 180/64 mmHg. The heart rate was irregular with 150 beats/min. The jugular venous pulse was elevated to 9 cm of water. There was murmur systolic on intercostal space (ICS) 5 anterior axilla line (AAL) sinistra and murmur diastolic on ICS 2 parasternal line (PSL) dextra. Respiratory rate of 28 breaths/min, oxygen saturation at the right arm was 92% without supplemental oxygen, and body mass index of 19,5 kg/m2.\nAn electrocardiogram showed atrial fibrillation (AF) with a rapid ventricular response. A routine laboratory examination did not show any abnormality. Chest X-ray showed cardiomegaly with calcification aortic arch and pulmonary edema. Echocardiography found that left ventricular ejection fraction (LVEF) was decreased (48,5%) with left atrial and ventricular dilatation. Echocardiography also found severe aortic and mitral valve regurgitation . He was diagnosed with congestive heart failure with mildly reduced ejection fraction (HFmrEF) and classified in New York Heart Association (NYHA) class IV.\nAfter one day of hospitalization, the patient also complained of intermittent claudication in the left arm. Clinical examination found an absence of the left brachial pulse and the left carotid artery bruit. Four limbs blood pressure discrepancy was present (right arm 163/50 mmHg, left arm 96/55 mmHg, right leg 90/60 mmHg, left leg 95/55 mmHg). Computed tomography angiography (CTA) showed calcification in the left common carotid artery leading to stenosis and total occlusion of the left subclavian artery with the collateral artery branch from the left common carotid artery that supplies vascularization of the left arm. There was vascular thickness and calcification from the peri-aortic valve, ascending aorta, aortic arch, and thoracic descending aorta until abdominal aorta with high-grade stenosis on the inferior side of the renal artery branching accompanied by a post-stenotic dilatation . Inflammatory markers evaluation that needed notable are elevation C-reactive protein (CRP) level (45,1 mg/L) and erythrocyte sedimentation rate (ESR) level (25 mm/h). Other laboratory evaluations were antinuclear antibody (ANA) titer, antistreptolysin O (ASO) titer, and interferon-gamma release assay (IGRA) showed negative results. He has subsequently diagnosed with Takayasu arteritis according to the American College of Rheumatology criteria.\nFor treatment of hypertension and HFmrEF, beta-blocker bisoprolol 2,5 mg/day, angiotensin-converting enzyme inhibitor (ACE-I) ramipril 5 mg/day, and mineralocorticoid receptor antagonists (MRA) spironolactone 25 mg/day therapy were initiated. Loop diuretic furosemide 40 mg/day is given to treat congestive symptoms of heart failure and glycoside digoxin 0,25 mg/day is given as rate control of atrial fibrillation. Anticoagulant warfarin 2 mg/day was given to prevent thromboembolism. A combination of methotrexate 7,5 mg/week and high-dose methylprednisolone at 48 mg/day with subsequent tapering was given for induction of remission to inhibition vasculitis of TA. After 3 months of high-dose steroid and methotrexate therapy, the patient showed a decrease in symptoms of NYHA class II for heart failure and a decrease in the frequency of rehospitalization. The patient also did not complain of claudication in the left arm. On physical examination, the patient's right arm blood pressure was 146/55 mmHg and the left arm was 105/50 mmHg. Follow-up evaluation of inflammatory markers CRP and ESR showed normal results.", "summary": "We report a 26-year-old male presented with severe dyspnea, palpitation, orthopnea, paroxysmal nocturnal dyspnea, and claudication in the left arm. Four limbs blood pressure discrepancy was present. Chest X-ray showed cardiomegaly with calcification aortic arch and pulmonary edema. Echocardiography revealed that left ventricular ejection fraction decreased with severe aortic and mitral valve regurgitation. Computed tomography angiography showed stenosis of the left common carotid artery and total occlusion of the left subclavian artery with collateral artery. There was vascular thickness and calcification from the peri-aortic valve, ascending aorta, aortic arch, and thoracic descending aorta until abdominal aorta with high-grade stenosis on the inferior side of the renal artery branching accompanied by a post-stenotic dilatation.", "subclaim_evaluations": [ { "subclaim": "The patient is a 26-year-old male.", "support_label": "supported" }, { "subclaim": "The patient had severe dyspnea.", "support_label": "supported" }, { "subclaim": "The patient had palpitation.", "support_label": "supported" }, { "subclaim": "The patient had orthopnea.", "support_label": "supported" }, { "subclaim": "The patient had paroxysmal nocturnal dyspnea.", "support_label": "supported" }, { "subclaim": "The patient had claudication in the left arm.", "support_label": "supported" }, { "subclaim": "There was a four limbs blood pressure discrepancy.", "support_label": "supported" }, { "subclaim": "Chest X-ray showed cardiomegaly.", "support_label": "supported" }, { "subclaim": "Chest X-ray showed calcification of the aortic arch.", "support_label": "supported" }, { "subclaim": "Chest X-ray showed pulmonary edema.", "support_label": "supported" }, { "subclaim": "Echocardiography showed decreased left ventricular ejection fraction.", "support_label": "supported" }, { "subclaim": "Echocardiography showed severe aortic valve regurgitation.", "support_label": "supported" }, { "subclaim": "Echocardiography showed severe mitral valve regurgitation.", "support_label": "supported" }, { "subclaim": "Computed tomography angiography showed stenosis of the left common carotid artery.", "support_label": "supported" }, { "subclaim": "Computed tomography angiography showed total occlusion of the left subclavian artery.", "support_label": "supported" }, { "subclaim": "Computed tomography angiography showed collateral artery formation.", "support_label": "supported" }, { "subclaim": "There was vascular thickness from the peri-aortic valve.", "support_label": "supported" }, { "subclaim": "There was vascular calcification from the ascending aorta.", "support_label": "supported" }, { "subclaim": "There was vascular calcification from the aortic arch.", "support_label": "supported" }, { "subclaim": "There was vascular calcification from the thoracic descending aorta.", "support_label": "supported" }, { "subclaim": "There was vascular calcification from the abdominal aorta.", "support_label": "supported" }, { "subclaim": "There was high-grade stenosis on the inferior side of the renal artery branching.", "support_label": "supported" }, { "subclaim": "There was post-stenotic dilatation.", "support_label": "supported" } ] }, { "id": "multiclinsum_test_3047_en.txt", "fulltext": "A 27-year-old female smoker with no regular medication, with no previous history of SARS-CoV-2 infection, vaccinated with BCG at birth in her left arm, received the first dose of the COVID-19 mRNA vaccine (Moderna®), also in her left arm, without symptoms or immediate intercorrerences, reporting no additional changes in the following days, namely, redness, heat, change in pigmentation or exudate. Eight days after administration of the anti-SARS-CoV2 mRNA vaccine, the young woman developed a reaction of a round shape and poorly defined edges with about 2 cm in diameter at the site of the BCG scar, characterized by erythema, induration and pain, and distanced about 4 cm from the site of inoculation of the anti-SARS-CoV2 vaccine. The patient did not report fever, myalgia or other symptoms. No changes were detected in the objective examination, namely, adenopathies. The symptoms persisted for three days, and the patient opted not to be medicated. After 11 days since the onset of symptoms, a complementary analytical study was performed, revealing a positive result for anti-SARS-CoV2 IgG, with the remaining values within the normal range, including lymphocytes and viral serologies. The incident was submitted as a possible adverse reaction to medicines in the National Pharmacovigilance System.\n", "summary": "Here is a case of a 27-year-old woman with no relevant history, including SARS-CoV-2 infection, who developed inflammation of the BCG scar eight days after the first administration of anti-SARS-CoV-2 mRNA vaccine.\n", "subclaim_evaluations": [ { "subclaim": "The patient is a 27-year-old woman.", "support_label": "supported" }, { "subclaim": "The patient had no relevant medical history.", "support_label": "supported" }, { "subclaim": "The patient had no prior SARS-CoV-2 infection.", "support_label": "supported" }, { "subclaim": "The patient developed inflammation of the BCG scar.", "support_label": "supported" }, { "subclaim": "The inflammation occurred eight days after the first administration of an anti-SARS-CoV-2 mRNA vaccine.", "support_label": "supported" } ] } ]