[ { "id": "multiclinsum_test_2292_en.txt", "fulltext": "A 65-year-old female with a history of type 2 diabetes mellitus, systemic arterial hypertension and long-standing right hearing loss. She began his condition 21 days before his initial evaluation in July 2023, presenting with moderate to intense holocranial headache that partially subsided with the use of non-steroidal anti-inflammatory drugs. She had previously been diagnosed with dementia due to retrograde memory and language disorders. In the neurological examination with Glasgow 13 points (O:4, V:3, M:6), mental functions with global aphasia, isocoria of 3 mm, preserving photomotor and consensual reflexes, right side conduction hearing loss, preserved motor function, sensitive without response to pain in the right hemibody. No evidence of intracranial hypertension or history of seizures. A simple and contrasted tomography was performed, showing the presence of two lesions at the level of both ventricular trigone each one apparently, which were confirmed by magnetic resonance imaging (MRI) scan indicating periventricular lesions with extension to the white matter of the temporal and parietal lobes, a clear reduction of the ventricular space of both atrium was observed, no communication between these lesions through fibers of the corpus callosum, with mostly uniform enhancement at gadolinium contrast , and restriction to diffusion. Metastasis, high-grade glioma, and lymphoma were considered as a differential diagnosis, which was complemented by a thoracic and abdominal tomography without evidence of systemic lesions. Serological studies were performed , viral profiles for EBV, CMV, and HIV, as well as tumor markers, which were all negative. Subsequently, a spectroscopy study was performed 8 days before treatment with dexamethasone, where peaks of choline and creatine were observed, a high choline/creatine (Cho/Cr) ratio, with peaks of lipids and lactate, as well as a decrease in N-acetyl aspartate (NAA), suggestive of malignancy and presence of areas of necrosis.\nA temporal craniotomy with a transulcal T2–T3 approach guided by a neuronavigation system was performed. Biopsy samples were taken. The tumor was identified as infiltrative and diffused in the white matter, with gray color, soft consistency, and necrotic core. The ventricle was not opened. No complications were presented.\nHistopathology revealed diffuse large B-cell lymphoma with an angiocentric pattern with positive immunohistochemical staining for CD20 and Ki67 in 70% .\nThe patient had a complicated course due to pneumonia, was discharged from the hospital 15 days after surgery, and was referred to an oncology center.", "summary": "A 65-year-old female presented progressing headache, loss of memory and language alterations, as well as sensory alterations. Neuroimaging showed the presence of two equidistant periventricular lesions at the level of both ventricular atria, a spectroscopy study suggestive of malignancy. Serological studies showed no evidence of immunodeficiency or the presence of positive tumor markers; however, a biopsy was performed, which revealed a histopathological result of primary lymphoma of the CNS.", "subclaim_evaluations": [ { "subclaim": "The patient is a 65-year-old female.", "support_label": "supported", "is_refined": false }, { "subclaim": "The patient had progressing headache.", "support_label": "supported", "is_refined": false }, { "subclaim": "The patient had loss of memory.", "support_label": "supported", "is_refined": false }, { "subclaim": "The patient had language alterations.", "support_label": "supported", "is_refined": false }, { "subclaim": "The patient had sensory alterations.", "support_label": "supported", "is_refined": false }, { "subclaim": "Neuroimaging showed two equidistant periventricular lesions at the level of both ventricular atria.", "support_label": "supported", "is_refined": false }, { "subclaim": "A spectroscopy study was suggestive of malignancy.", "support_label": "supported", "is_refined": false }, { "subclaim": "Serological studies showed no evidence of immunodeficiency.", "support_label": "supported", "is_refined": false }, { "subclaim": "Serological studies showed no presence of positive tumor markers.", "support_label": "supported", "is_refined": false }, { "subclaim": "A biopsy was performed.", "support_label": "supported", "is_refined": false }, { "subclaim": "The histopathological result was primary lymphoma of the CNS.", "support_label": "supported", "is_refined": false } ] }, { "id": "multiclinsum_test_2759_en.txt", "fulltext": "A 66-year-old Maori man presented to our hospital with a history of an enlarged left testicle of 10 weeks’ duration. His clinical examination revealed nontender swelling of the left testicle. His alpha-fetoprotein (AFP) and beta-human chorionic gonadotropin (BHCG) levels were within normal limits. His lactate dehydrogenase (LDH) concentration was mildly elevated at 267 U/L (normal range 120–250 U/L). Ultrasonography of his testes demonstrated an enlarged left testicle measuring 7 × 5.5 × 4.3 cm with an estimated volume of 87 ml. A large, heterogeneous mass involved the entire testicle with increased vascularity . The patient’s right testicle measured 3.7 × 2.5 × 1.8 cm with an estimated volume of 8.8 ml. He underwent left orchiectomy. The macroscopic specimen consisted of well-circumscribed nodular lesions of varying sizes, with the largest measuring 45 × 15 mm and containing solid and gelatinous components . Sections of the specimen showed tumor composed of sheets of small, blue, round cells divided into nodules by fibrous septae . Immunostaining showed the tumor to be cytokeratin 20 (CK20)-positive with a typical paranuclear dotlike staining pattern . The stain showed a positive result for CD56, a neuroendocrine marker , as were CD117 and CK (paranuclear dots). The result was negative for CK7, placental alkaline phosphatase (PLAP), CD30, CD20, AFP, S100, SOX10, prostate-specific antigen (PSA), chromogranin, and thyroid transcription factor 1 (TTF-1). The Ki-67 level was >50 %. This immunostaining pattern raised the possibility of metastatic MCC.\nThe patient presented again to our hospital 3 months later this time with a right testicular mass. Tumor markers, including LDH, AFP, and BHCG, were within normal limits. Ultrasonographic imaging demonstrated a new lesion in the right testis measuring 3 × 2.6 × 2.3 cm. He underwent a right orchiectomy, and sections of the specimen showed diffuse infiltration of small, blue, round cells. Immunostains were positive for CD117, CD56, synaptophysin, CK20 (dotlike), and cytokeratin AE1/AE3 (dotlike). The tumor cells were negative for inhibin, PLAP, PSA, S100, CD30, CD45, CD3, CD20, TTF-1, and napsin A. The Ki-67 level was 80 %. This pattern was consistent with a poorly differentiated neuroendocrine tumor in keeping with metastatic MCC. Detailed histology reports can be found in Additional files and . A primary site was not identified, and a staging computed tomographic scan did not show evidence of other metastases. The patient received six cycles of adjuvant carboplatin and etoposide chemotherapy. He remained disease-free 18 months following completion of chemotherapy.", "summary": "A 66-year-old Maori man presented to our hospital with left testicular swelling. His alpha-fetoprotein and beta-human chorionic gonadotrophin levels were within normal limits. His lactate dehydrogenase concentration was elevated to 267 U/L. Ultrasound imaging confirmed a large testicular mass, and he underwent left orchiectomy. His histological examination revealed a neuroendocrine tumor with an immunostaining pattern suggesting Merkel cell carcinoma. He presented to our hospital again 3 months later with right testicular swelling that was confirmed on ultrasound sonography to be a tumor. He underwent a right orchiectomy, and his histological examination revealed metastatic Merkel cell carcinoma. A primary lesion was not identified, and computed tomographic imaging did not reveal spread to other organs. He received six cycles of adjuvant carboplatin and etoposide chemotherapy and remained disease-free 18 months after completion of chemotherapy.", "subclaim_evaluations": [ { "subclaim": "The patient is a 66-year-old Maori man.", "support_label": "supported", "is_refined": false }, { "subclaim": "He presented with left testicular swelling.", "support_label": "supported", "is_refined": false }, { "subclaim": "His alpha-fetoprotein levels were within normal limits.", "support_label": "supported", "is_refined": false }, { "subclaim": "His beta-human chorionic gonadotrophin levels were within normal limits.", "support_label": "supported", "is_refined": false }, { "subclaim": "His lactate dehydrogenase concentration was elevated to 267 U/L.", "support_label": "supported", "is_refined": false }, { "subclaim": "Ultrasound imaging confirmed a large testicular mass.", "support_label": "supported", "is_refined": false }, { "subclaim": "He underwent left orchiectomy.", "support_label": "supported", "is_refined": false }, { "subclaim": "Histological examination revealed a neuroendocrine tumor.", "support_label": "supported", "is_refined": false }, { "subclaim": "The immunostaining pattern suggested Merkel cell carcinoma.", "support_label": "supported", "is_refined": false }, { "subclaim": "He presented again 3 months later with right testicular swelling.", "support_label": "supported", "is_refined": false }, { "subclaim": "Ultrasound sonography confirmed a tumor in the right testicle.", "support_label": "supported", "is_refined": false }, { "subclaim": "He underwent right orchiectomy.", "support_label": "supported", "is_refined": false }, { "subclaim": "Histological examination revealed metastatic Merkel cell carcinoma.", "support_label": "supported", "is_refined": false }, { "subclaim": "A primary lesion was not identified.", "support_label": "supported", "is_refined": false }, { "subclaim": "Computed tomographic imaging did not reveal spread to other organs.", "support_label": "supported", "is_refined": false }, { "subclaim": "He received six cycles of adjuvant carboplatin and etoposide chemotherapy.", "support_label": "supported", "is_refined": false }, { "subclaim": "He remained disease-free 18 months after completion of chemotherapy.", "support_label": "supported", "is_refined": false } ] }, { "id": "multiclinsum_test_3113_en.txt", "fulltext": "A 41-year old male was in good health before. He suffered from progressive exertional dyspnea and visited an outpatient department of local hospital, but then was transferred to our hospital because of LV thrombus which was found on transthoracic echocardiogram. After admission to our ward, transthoracic echocardiogram showed global hypokinetic LV (the EF of LV was 28%), dilated LV size and a pedunculated apical thrombus measuring 1.75 × 1.68 cm. Coronary angiogram was performed to rule out ischemic cardiomyopathy and it subsequently revealed no significant obstructive lesion. He was discharged from our hospital and had taken warfarin 3.75 mg/day for AF and LV thrombus since then.\n\nHowever, he developed sudden onset of right-hand clumsiness and expressive aphasia after 1 month and was sent to our emergency department immediately for help. Right eye blurred vision and drooling from the right mouth angle were noted at the same time. The blood examination in the emergency department showed supratherapeutic range of prothrombin time and international normalized ratio (INR) 7.64. His symptoms totally recovered within 1 day, but the brain magnetic resonance imaging (MRI) showed multiple acute infarctions in the cortex of the bilateral frontal lobes, left parietal lobe, and bilateral central semiovale, which highly suggested embolic stroke. The transthoracic echocardiogram performed on the same day of stroke still revealed LV thrombus (1.27 × 0.90 cm). Due to acute infarction even under high INR level, we discontinued warfarin first and shifted to edoxaban (60 mg/day) use after INR decreased to less than 2.\n\nTo our surprise, follow-up echocardiography showed resolution of LV thrombus after receiving edoxaban for 23 days. The patient tolerated edoxaban well and did not get recurrent stroke in the following 6 months.", "summary": "Patient concerns:\nA 41-year-old man who presented with acute onset of right-hand clumsiness and aphasia even under high international normalized ratio (INR: 7.64) from warfarin use. He was previously treated with warfarin for the LV thrombus and non-valvular AF. Brain magnetic resonance imaging (MRI) showed multiple acute infarction in the cortex of the bilateral frontal lobes, left parietal lobe, and bilateral central semiovale, which highly suggested embolic stroke.\n\nDiagnosis:\nThe repeated transthoracic echocardiogram still revealed LV thrombus (1.27 × 0.90 cm), which failed to respond to warfarin therapy.\n\nInterventions:\nDue to acute infarctions occurred under supratherapeutic range of INR, we switched warfarin to edoxaban (dose: 60 mg/day) after INR decreased to less than 2.\n\nOutcomes:\nThe thrombus disappeared after receiving edoxaban for 23 days, and no more recurrent stroke was noted for more than 6 months.", "subclaim_evaluations": [ { "subclaim": "The patient is a 41-year-old man.", "support_label": "supported", "is_refined": false }, { "subclaim": "He presented with acute onset of right-hand clumsiness.", "support_label": "supported", "is_refined": false }, { "subclaim": "He had aphasia.", "support_label": "supported", "is_refined": false }, { "subclaim": "His international normalized ratio (INR) was 7.64.", "support_label": "supported", "is_refined": false }, { "subclaim": "He was using warfarin.", "support_label": "supported", "is_refined": false }, { "subclaim": "He had a history of left ventricular (LV) thrombus.", "support_label": "supported", "is_refined": false }, { "subclaim": "He had non-valvular atrial fibrillation.", "support_label": "not_supported", "original_label": "not_supported", "reasoning_audit": "No explicit tags provided.", "is_refined": true }, { "subclaim": "Brain MRI showed multiple acute infarctions.", "support_label": "supported", "is_refined": false }, { "subclaim": "The infarctions were in the cortex of the bilateral frontal lobes.", "support_label": "supported", "is_refined": false }, { "subclaim": "The infarctions were in the left parietal lobe.", "support_label": "supported", "is_refined": false }, { "subclaim": "The infarctions were in the bilateral central semiovale.", "support_label": "supported", "is_refined": false }, { "subclaim": "The MRI findings suggested embolic stroke.", "support_label": "supported", "is_refined": false }, { "subclaim": "A transthoracic echocardiogram showed LV thrombus.", "support_label": "supported", "is_refined": false }, { "subclaim": "The LV thrombus measured 1.27 × 0.90 cm.", "support_label": "supported", "is_refined": false }, { "subclaim": "The LV thrombus did not respond to warfarin therapy.", "support_label": "supported", "is_refined": false }, { "subclaim": "Warfarin was switched to edoxaban.", "support_label": "supported", "is_refined": false }, { "subclaim": "The switch occurred after INR decreased to less than 2.", "support_label": "supported", "is_refined": false }, { "subclaim": "The edoxaban dose was 60 mg/day.", "support_label": "supported", "is_refined": false }, { "subclaim": "The LV thrombus disappeared after 23 days of edoxaban.", "support_label": "supported", "is_refined": false }, { "subclaim": "No recurrent stroke was noted for more than 6 months.", "support_label": "supported", "is_refined": false } ] }, { "id": "multiclinsum_test_612_en.txt", "fulltext": "We present a case of a 54-year-old Chinese man with a history of treated hypertension and diabetes mellitus, referred for suspected spontaneous left dural CCF. The patient complained of a chronically red left eye and double vision in the left gaze. Initial examination disclosed best corrected visual acuity 20/20 in the right eye and 20/25 in the left eye, associated with a left relative afferent pupillary defect and severely reduced color vision on Ishihara testing in his left eye only. Humphrey visual field assessment disclosed diffuse defects in the left eye, but was normal in the right eye. Slit lamp examination disclosed a red left eye with dilated corkscrew vessels, but no evidence of angle closure, blood in the Schlemm canal, or other causes of raised intraocular pressure. Intraocular pressure (IOP) was 28 mmHg in the left eye, and 14 mmHg in the right, healthy eye. Fundoscopy disclosed dilated retinal veins on the left side, but no venous stasis retinopathy, or choroidal detachment. The remainder of the ophthalmic examination disclosed mild left abduction deficit, mild ptosis and 3 mm proptosis on the left side. Partial embolization of the angiographically confirmed left dural CCF resulted in incomplete clinical recovery: despite complete regression of the left optic neuropathy and of the left abduction deficit, the left eye remained red, associated with raised intraocular pressure requiring topical medication. Optical coherence tomography angiography of the anterior segment was performed, using a described technique , with optic disc imaging as well using the AngioVue (Optovue Inc. Fremont, CA, USA). Our study followed the principles of the Declaration of Helsinki, with informed consent obtained and ethics approval obtained from our local Institutional Review Board (CIRB Ref no: 2015/3078). OCTA showed engorged episcleral vessels, which were better delineated than using clinical evaluation alone . The OCTA was able to analyze the location and depth of the tortuous, abnormal vessels, as well as the increased flow detected on the B-scan cross-sectional OCTA scans . Posterior pole OCTA of the affected eye disclosed glaucomatous nerve damage and reduction in the peripapillary flow .", "summary": "We describe a novel clinical application of OCTA in a patient with dural carotid-cavernous sinus fistula (CCF), which was complicated by increased intra-ocular pressure (IOP). In this case report, we used the OCTA to delineate increased epsicleral venous flow in the affected eye with secondary raised IOP. Current measurements of episcleral venous pressure are either invasive or provide highly variable results, thus the OCTA may have the potential to provide a more reliable approach to assess episcleral vasculature. We also describe the use of OCTA to detect early glaucomatous nerve damage, associated with focal reductions in peripapillary retinal perfusion.", "subclaim_evaluations": [ { "subclaim": "The patient had a dural carotid-cavernous sinus fistula.", "support_label": "supported", "is_refined": false }, { "subclaim": "The patient had increased intra-ocular pressure.", "support_label": "supported", "is_refined": false }, { "subclaim": "OCTA was used to delineate increased episcleral venous flow in the affected eye.", "support_label": "supported", "is_refined": false }, { "subclaim": "The increased episcleral venous flow was associated with secondary raised intra-ocular pressure.", "support_label": "supported", "is_refined": false }, { "subclaim": "Current measurements of episcleral venous pressure are either invasive or provide highly variable results.", "support_label": "not_supported", "original_label": "not_supported", "reasoning_audit": "No explicit tags provided.", "is_refined": true }, { "subclaim": "OCTA may provide a more reliable approach to assess episcleral vasculature.", "support_label": "supported", "is_refined": false }, { "subclaim": "OCTA was used to detect early glaucomatous nerve damage.", "support_label": "supported", "is_refined": false }, { "subclaim": "Early glaucomatous nerve damage was associated with focal reductions in peripapillary retinal perfusion.", "support_label": "supported", "is_refined": false } ] }, { "id": "multiclinsum_test_2609_en.txt", "fulltext": "In June 2018, a 57-year-old woman presented with a massive, painless mass in the right orbit which had developed over 19 years. As the tumor grew, vision in the right eye gradually deteriorated until it was completely lost approximately 15 years before presentation. Due to budgetary constraints, the patient avoided seeking appropriate medical care.\nUpon ophthalmological examination, she had a best-corrected visual acuity of no light perception and 20/20 of the right and left eyes, respectively. In the right orbit, a large rubbery mass stretched horizontally from the bridge of the nose to the lateral canthus, and vertically from the eyebrow to the center of the cheek. The upper eyelid covering the tumor was pushed forward due to the large size of the mass. The vessels of the eyelids were dilated and tortuous . The palpebral fissure was elongated and widened; the eyeball, covered with soft tissue, was displaced anteromedially . No abnormalities were observed in the left eye. There was no associated lymphadenopathy and a systemic examination revealed no abnormalities.\nOrbital CT revealed a huge mass in the right orbit measuring 10.6 × 9.5 × 11 cm. After administration of contrast material, inhomogeneous enhancement and vascular-like enhancing structures were observed. The mass was closely related to the internal rectus muscle. The eyeball appeared totally engulfed and compressed by the large mass and was displaced anteromedially. In the bone structures, no evident erosion or extension damage was found; however, the temporal orbital wall was observed to be slightly thinner than anticipated .\nOrbital cavernous hemangioma was suspected. The patient underwent lid-sparing orbital exenteration under general anesthesia, a procedure that involved removal of the tumor, globe, orbital contents, and most of the upper eyelid. Using a preserved part of the normal eyelid skin, the orbital cavity was covered and sutured with a skin incision margin.\nOn gross pathological examination, the orbital lesion consisted of a 15 × 13 × 9 cm well-circumscribed solid tumor covered with a 16 × 14 cm flap . The cut surface was composed of gray-white or gray-red soft tissue with foci of hemorrhage identified in some areas. Nerve tissue of approximately 2.5 cm in length and 0.2 cm in diameter was observed in the adipose tissue next to the tumor. On microscopic examination, H&E staining showed that the tumor tissue constituted spindle-shaped cells arranged in bundles or irregular shapes. Cell nuclei were oval or spindle-shaped. No necrosis, mitoses, or nuclear pleomorphisms were present. .\nIHC testing demonstrated strong and diffuse spindle cells with antibodies against CD34, signal transducer and activator of transcription 6 (STAT6) , B-cell lymphoma 2 (BCL-2), and progesterone receptors (PR). Approximately 2% of these cells were reactive to Ki-67. Staining for antibodies against P53, glial fibrillary acidic protein, and S-100 was negative. These findings were compatible with a diagnosis of a benign SFT.\nThe patient had good cosmetic results and exhibited no symptoms of recurrence during the 4-year follow-up.", "summary": "A 57-year-old woman presented with a 19-year history of a giant right orbital mass. Orbital computed tomography (CT) revealed an inhomogeneously-enhancing mass compressing and engulfing the eyeball and optic nerve. She underwent lid-sparing orbital exenteration. Microscopic characteristics and immunohistochemistry (IHC) tests were indicative of a benign SFT. No recurrence was observed at the 4-year follow-up.", "subclaim_evaluations": [ { "subclaim": "The patient is a 57-year-old woman.", "support_label": "supported", "is_refined": false }, { "subclaim": "She had a 19-year history of a giant right orbital mass.", "support_label": "supported", "is_refined": false }, { "subclaim": "Orbital CT showed an inhomogeneously-enhancing mass.", "support_label": "supported", "is_refined": false }, { "subclaim": "The mass was compressing and engulfing the eyeball.", "support_label": "supported", "is_refined": false }, { "subclaim": "The mass was compressing and engulfing the optic nerve.", "support_label": "not_supported", "original_label": "not_supported", "reasoning_audit": "No explicit tags provided.", "is_refined": true }, { "subclaim": "She underwent lid-sparing orbital exenteration.", "support_label": "supported", "is_refined": false }, { "subclaim": "Microscopic characteristics were indicative of a benign SFT.", "support_label": "supported", "is_refined": false }, { "subclaim": "Immunohistochemistry tests were indicative of a benign SFT.", "support_label": "supported", "is_refined": false }, { "subclaim": "No recurrence was observed at the 4-year follow-up.", "support_label": "supported", "is_refined": false } ] }, { "id": "multiclinsum_test_785_en.txt", "fulltext": "Left limb weakness for 1 d.\nA 38-year-old female presented to the Moyamoya Disease Research and Treatment Center of Henan Provincial People's Hospital with \"left limb weakness\" as the main symptom, in addition to difficulty in lifting the left arm and walking with dragging of the left leg. On further inquiry, her regular medication included the long-term consumption of aspirin (100 mg/d) for recurrent transient ischemic attack.\nFour months previously, she had been diagnosed with an acute cerebral infarction by a brain MRI in our hospital following the complaints of \"weakness of lower limbs\" . Additionally, she had also experienced abnormal uterine bleeding for a month, which was heavy at times.\nThere was no significant past personal history or any diseases running in the family. She was not a smoker and did not drink alcohol.\nThe patient was conscious but in poor spirits. The tongue appeared skewed to the left on extension. The left upper and lower limbs had muscle strengths of grade 3 and grade 4, respectively, with a positive Babinski sign on the left.\nThe blood investigation showed a low hemoglobin level of 61.0 (normal reference value: 115-150 g/L), RBC count 3.1 × 1012/L (reference value 3.5-5.0), platelet count 350 × 109/L (reference value 100-300), and abnormal thromboelastogram (residual platelet function after taking ADP drugs = 14.2 mm, normal reference value: 31-47 mm). The coagulation was slightly low.\nUpon admission, the first brain magnetic resonance imaging (MRI) (diffusion weighted imaging sequence) revealed acute cerebral infarction in the bilateral fronto-parietal lobes and posterior horn of the left ventricle . Preoperatively, the digital subtraction angiography (DSA) demonstrated bilateral internal carotid artery occlusion , with cerebral perfusion perfusion-weighted imaging (PWI) suggesting severe cerebral ischemia in both hemispheres .", "summary": "A 38-year-old female presented to the Research and Treatment Center of Moyamoya Disease in our hospital with \"left limb weakness\" as the main symptom. She was diagnosed with acute cerebral infarction and moyamoya disease through magnetic resonance imaging and digital subtraction angiography. Prior to this, she had experienced a prolonged menstrual period of one-month duration. This was investigated and adenomyosis was diagnosed. After passing the acute cerebral infarction phase, the patient underwent surgery for adenomyosis followed by combined cerebral revascularization. During the postoperative follow-up, improvements of the perfusion imaging stage and modified Rankin Scale were observed. A review of the literature showed only 16 reported cases of gynecological diseases complicated with stroke. The clinical characteristics, pathogenesis, therapeutic effects, and long-term prognosis of these cases have been studied and discussed.", "subclaim_evaluations": [ { "subclaim": "The patient is a 38-year-old female.", "support_label": "supported", "is_refined": false }, { "subclaim": "She presented to the Research and Treatment Center of Moyamoya Disease.", "support_label": "supported", "is_refined": false }, { "subclaim": "Her main symptom was left limb weakness.", "support_label": "supported", "is_refined": false }, { "subclaim": "She was diagnosed with acute cerebral infarction.", "support_label": "supported", "is_refined": false }, { "subclaim": "She was diagnosed with moyamoya disease.", "support_label": "supported", "is_refined": false }, { "subclaim": "The diagnosis was made through magnetic resonance imaging.", "support_label": "supported", "is_refined": false }, { "subclaim": "The diagnosis was made through digital subtraction angiography.", "support_label": "supported", "is_refined": false }, { "subclaim": "She had a prolonged menstrual period of one-month duration.", "support_label": "supported", "is_refined": false }, { "subclaim": "Adenomyosis was diagnosed.", "support_label": "not_supported", "original_label": "not_supported", "reasoning_audit": "No explicit tags provided.", "is_refined": true }, { "subclaim": "The patient underwent surgery for adenomyosis.", "support_label": "not_supported", "original_label": "not_supported", "reasoning_audit": "No explicit tags provided.", "is_refined": true }, { "subclaim": "The patient underwent combined cerebral revascularization.", "support_label": "not_supported", "original_label": "not_supported", "reasoning_audit": "No explicit tags provided.", "is_refined": true }, { "subclaim": "Improvements of the perfusion imaging stage were observed.", "support_label": "not_supported", "original_label": "not_supported", "reasoning_audit": "No explicit tags provided.", "is_refined": true }, { "subclaim": "Improvements of the modified Rankin Scale were observed.", "support_label": "not_supported", "original_label": "not_supported", "reasoning_audit": "No explicit tags provided.", "is_refined": true }, { "subclaim": "A review of the literature showed 16 reported cases of gynecological diseases complicated with stroke.", "support_label": "not_supported", "original_label": "not_supported", "reasoning_audit": "No explicit tags provided.", "is_refined": true }, { "subclaim": "The clinical characteristics of these cases have been studied.", "support_label": "not_supported", "original_label": "not_supported", "reasoning_audit": "No explicit tags provided.", "is_refined": true }, { "subclaim": "The pathogenesis of these cases has been discussed.", "support_label": "not_supported", "original_label": "not_supported", "reasoning_audit": "No explicit tags provided.", "is_refined": true }, { "subclaim": "The therapeutic effects of these cases have been studied.", "support_label": "not_supported", "original_label": "not_supported", "reasoning_audit": "No explicit tags provided.", "is_refined": true }, { "subclaim": "The long-term prognosis of these cases has been discussed.", "support_label": "not_supported", "original_label": "not_supported", "reasoning_audit": "No explicit tags provided.", "is_refined": true } ] }, { "id": "multiclinsum_test_1242_en.txt", "fulltext": "A 61-year-old German woman presented to our orthopedic clinic after Felix IV fracture in revision total knee arthroplasty. Two years ago, the patient had undergone revision TKA with a rotating hinge prosthesis complicated by an intraoperative fracture of the tibial tubercle. Screw fixation had been performed, but 3 months later nonunion of the fragment had persisted, resulting in plate osteosynthesis with a one-third tubular plate. After another dislocation of the tibial tubercle, the patient presented to our clinic with anterior knee pain, loss of extension strength, and a feeling of rotational instability. On clinical examination, pressure pain of the proximal tibia, decreased extension strength to Janda 3/5, and inability to raise the extended knee were noticed. This maintained extensor function is the result of an intact medial and lateral retinaculum. The knee’s range of motion was 0–110° of flexion with preserved mediolateral and anterior/posterior stability. X-ray showed the rotation hinge prosthesis without loosening signs, the one-third tubular plate, and the dislocated tibial tubercle fragment indicating persistent Felix IV C fracture .\nReconstruction of the knee joint’s extension system was planned. After preparation of the subcutaneous tissue, the dislocated tibial tubercle appeared surrounded by extensive metallosis presumably induced by the contact between the one-third tubular plate and the tibial prosthesis. Following the removal of the plate, the fragment proved to be necrotic requiring a total extirpation instead of mobilization and refixation. Subsequently, the ventral surface of the tibial prosthesis was exposed . Reconstruction of the extension system should be performed by the implantation of MUTARS attachment tube made of polyethylene terephthalate. Since the tibial prosthesis did not offer any connecting points for the synthetic graft, cement was used as an extender to simultaneously serve as fixing point and to preserve the prosthesis from loosening. Afterwards, the tube was doubled into a laminar sheet and fixed with two cancellous bone screws in the ventral tibia . ORTHOCORD sutures were used to attach the tube to the articular capsule still beyond the patella . Extensive jet lavage was performed before wound closure. Check of patellar tracking was promising; likewise, postoperative X-ray showed regular patella position .\nTo support the integration of the tube in the surrounding subcutaneous tissue, knee flexion was at first limited to 30° and then escalated to 60° and 90° every 2 weeks with full weight-bearing.\nFollow-up was performed after 3 and 10 months. On clinical examination , the patient showed irritant-free skin and soft tissue conditions; no redness or overheating; extension/flexion 0–0–110°; straight-leg raise completely possible; and force level 4/5 on side comparison of the knee stretchers. Active knee stretching with a flexed knee joint was possible without any problems. There was a centered patella run and no subluxation of the patella. Peripheral circulation, motor skills, and sensitivity were intact. X-ray confirmed correct implant position and central patella tracking . The patient was highly pleased by the restored extension function and significantly reduced knee pain.", "summary": "A 61-year-old German patient presented to our clinic with Felix IV C fracture, persistent knee pain, and reduced knee extension strength. In this special case, mobilization and reattachment of the tibial tubercle was not possible because of necrosis and underlying tibial component. Therefore, we covered the defect with cement and used an polyethylene terephthalate tube for knee extension system augmentation. Follow-up after 10 months demonstrated a good clinical result.", "subclaim_evaluations": [ { "subclaim": "The patient is a 61-year-old German.", "support_label": "supported", "is_refined": false }, { "subclaim": "The patient had a Felix IV C fracture.", "support_label": "supported", "is_refined": false }, { "subclaim": "The patient had persistent knee pain.", "support_label": "supported", "is_refined": false }, { "subclaim": "The patient had reduced knee extension strength.", "support_label": "supported", "is_refined": false }, { "subclaim": "Mobilization and reattachment of the tibial tubercle was not possible.", "support_label": "supported", "is_refined": false }, { "subclaim": "The reason for not reattaching the tibial tubercle was necrosis.", "support_label": "supported", "is_refined": false }, { "subclaim": "The reason for not reattaching the tibial tubercle was an underlying tibial component.", "support_label": "not_supported", "original_label": "not_supported", "reasoning_audit": "No explicit tags provided.", "is_refined": true }, { "subclaim": "The defect was covered with cement.", "support_label": "supported", "is_refined": false }, { "subclaim": "A polyethylene terephthalate tube was used.", "support_label": "supported", "is_refined": false }, { "subclaim": "The tube was used for knee extension system augmentation.", "support_label": "supported", "is_refined": false }, { "subclaim": "Follow-up occurred after 10 months.", "support_label": "supported", "is_refined": false }, { "subclaim": "The clinical result after 10 months was good.", "support_label": "supported", "is_refined": false } ] }, { "id": "multiclinsum_test_869_en.txt", "fulltext": "The patient was a 3 years old girl who for 2 months had symptoms and signs of disease with fever and reduced general condition. The last week she had nose bleedings, petechiae, and pain from the throat and abdomen. The initial blood tests showed hemoglobin 4.3 g/dL (normal 11–14 g/dL), leukocytes 72 × 109/L (normal 4 × 109/L–15 × 109/L), and thrombocytes 19 × 109/L (normal 150 × 109/L–450 × 109/L). The blood and bone marrow smears revealed that the patient had acute lymphoblastic leukemia. Immunophenotyping of peripheral blood showed 80% pre-B-lymphoblasts, in the bone marrow 88%. The patient was treated according to the NOPHO ALL 2008 protocol, high-risk group . She started with induction treatment, but the bone marrow on day 15 showed 90% lymphoblasts. The treatment was therefore changed to block treatment according to the protocol, and on day 34 minimal residual disease (MRD) was less than 0.01%. Also repeated later measurements have shown MRD of less than 0.01%.\nThe G-banding analysis at diagnosis of bone marrow and blood metaphase cells revealed a normal karyotype, 46,XX, in all 25 examined metaphases . Interphase FISH analyses with the Cytocell (Cytocell, Banbury, Oxfordshire, UK) multiprobe ALL panel did not detect aberrations of MYC, CDKN2A, TCF3, MLL, and IGH, no ETV6-RUNX1 or BCR-ABL1 fusions, nor was hyperdiploidy seen in 200 examined nuclei (data not shown). FISH with the PDGFRB breakapart probe (Cytocell) showed loss of the distal part of the probe in 176 out of 201 examined interphase nuclei from white blood cells and 42 out of 100 examined interphase nuclei from bone marrow cells, suggesting a genetic breakpoint in the PDGFRB locus in 5q32 .\naCGH was performed with genomic DNA extracted from the patientʼs peripheral blood cells using the Maxwell 16 Instrument System and the Maxwell 16 Cell DNA Purification Kit (Promega, Madison, USA). Promegaʼs human genomic female DNA (Promega, Madison, USA) was used as reference DNA. For aCGH, the CytoSure array products were used (Oxford Gene Technology, Begbroke, Oxfordshire, UK) following the company’s protocols. The CytoSure Genomic DNA Labelling Kit was used for labelling of one μg of patient’s and reference DNA, the CytoSure Cancer +SNP array was used for hybridization, and the CytoSure Interpret analysis software was used to analyse the results.\naCGH revealed submicroscopic deletions in chromosome bands 5q32q35.3, 7q34 (within TCRB), 9p13 (PAX5), 10q26.13 (DMBT1), 14q11.2 (TRAC), and 14q32.33 (within the IGH locus) . The deletion on 5q was 30 Mb long, started between exons 8 and 9 of PDGFRB (5q32), and finished in the CANX locus (5q35.3). The result was in agreement with the FISH data obtained with the PDGFRB breakapart probe . Because both FISH and aCGH findings indicated a possible PDGFRB-fusion gene, one µg of the total RNA, extracted from the patient´s bone marrow at the time of diagnosis using miRNeasy Mini Kit (Qiagen Nordic, Oslo, Norway), was sent to the Genomics Core Facility at the Norwegian Radium Hospital, Oslo University Hospital for high-throughput paired-end RNA-sequencing. For library preparation from total RNA the Illumina TruSeq RNA Access Library Prep kit was used according to Illuminaʼs protocol (Illumina, San Diego, CA, USA; ). Sequencing was performed on NextSeq 550 System (Illumina) and 16 million reads were generated.\nBecause the raw fastq RNA sequencing data were in the text-based format, we used the “grep” command-line utility to search for sequences which contained part of the ninth exon of PDGFRB . Using the search term “TCCCTGTCCGAGTGCTGG”, which corresponds to 1713–1730 nt in the PDGFRB reference sequence with accession number NM_002609.3, only one 76 bp long sequence was extracted . BLAT of this sequence on the human genome browser-hg19 assembly showed that the sequence between nucleotides 26–76 mapped on chromosome 5 at position 149510177–149510227 and was part of exon 9 of PDGFRB. The sequence between nucleotides 1–27 (GCCAGTTGGAAGTTCCAGCCACAGAAG) mapped on chromosome 7 at three different positions: (a) chr7:74172307–74172333 (exon 32 of general transcription factor Iii, GTF2I, reference sequence: NM_032999.3), (b) chr7: 74603796–74603822 (exon 22 of general transcription factor IIi pseudogene 1, GTF2IP1, reference sequence: NR_002206.3), and (c) chr7:72618618–72618644 (exon 22 of general transcription factor IIi pseudogene 4, GTF2IP4, reference sequence: NR_003580.2). These data were verified when we used the BLAST algorithm to compare the sequence with the reference sequences NM_002609.3 (PDGFRB), NM_032999.3 (GTF2I), NR_002206.3 (GTF2IP1), and NR_003580.2 (GTF2IP4).\nIn order to confirm the existence of the GTF2I–PDGFRB fusion gene, reverse transcription (RT) and genomic PCR analyses were performed as previously described . The primers used for PCR amplifications and Sanger sequencing analyses are shown in Table . RT-PCR with the primers GTF2I-3306F1/PDGFRB-1732R1 amplified an 84 bp long cDNA fragment. Sanger sequencing of the PCR products verified the fusion which was found upon searching the RNA sequencing data using the “grep” command . Thus, the leukemic cells carried either the fusion transcript GTF2IP1-PDGFRB, or GTF2I–PDGFRB, or GTF2IP4-PDGFRB. Genomic PCR with the primers GTF2I-3317F1 and PDGFRB-1737R1 amplified a single 1200 bp fragment which by Sanger sequencing was shown to be a hybrid genomic DNA fragment in which intron 8 of PDGFRB is fused with either intron 22 of GTF2IP1, intron 32 of GTF2I, or intron 22 of GTF2IP4 . Additional interphase FISH experiments were performed to detect the GTF2I–PDGFRB fusion gene . BACs RP11-21I20 and RP11-137E8 were retrieved from the Human “32K” BAC Re-Array library (BACPAC Resources, ). RP11-21I20, the probe for the PDGFRB gene, mapped to band 5q32 (Position: chr5: 149,320,375–149,496,703; UCSC Genome Browser on Human February 2009 GRCh37/hg19 Assembly) and was labeled red . RP11-137E8, the probe for the GTF2I gene, mapped to band 7q11.23 (Position: chr7: 73,944,720–74,129,587) and was labeled green . Detailed information about the FISH procedure was given previously . Fluorescent signals were captured and analyzed using the CytoVision system (Leica Biosystems, Newcastle, UK). FISH analysis showed a fusion signal in 44 out of 100 examined interphase nuclei from bone marrow cells suggesting a GTF2I–PDGFRB fusion gene . Thus, FISH with specific probes for PDGFRB and GTF2I was crucial to show that a novel GTF2I–PDGFRB fusion gene had been formed .\nUsing the FusionCatcher software with the fastq files of the RNA sequencing data, an out-of-frame IKZF1–TYW1 fusion transcript was found .\nRT-PCR with the primers IKZF1-469F1/TYW1-1282R1 amplified a 319 bp long cDNA fragment which by Sanger sequencing was shown to contain IKZF1–TYW1 . The fusion point thus detected was identical to that found by analysis of the RNA sequencing data using the FusionCatcher software . In the IKZF1–TYW1 transcript, exon 4 of IKZF1 (nt 642 in sequence with accession number NM_006060 version 6) was fused out-of-frame to exon 8 of TYW1 (nt 1131 in NM_018264 version 4) .\nThe IKZF1–TYW1 fusion gene would encode a putative truncated 159 aa IKZF1 protein containing the first 140 aa of IKZF1 (NP_006051) and 19 aa from the fused TYW1. This protein would not contain the functional domains of the normal IKZF1 protein. Alterations of IKZF1 (often deletions) are strongly associated with BCR-ABL1-positive as well as Ph-like ALL [, ].\nAdditional interphase FISH experiments were performed to detect the IKZF1–TYW1 fusion gene using a home-made dual color dual fusion probe. The probes were made from commercial BACs which were purchased from BACPAC Resources Center . The probe for the IKZF1 gene was constructed from a pool of the clones RP11-813K3 (Accesion number AC020743; Position: chr7: 50157413–50339940) and RP11-95E2 (Accesion number AC018705; chr7: 50475184–50648153) and was labeled red . The probe for the TYW1 gene was constructed from a pool of the clones RP11-458F8 (Accesion number AC073335; Position: chr7: 66297269–66454983) and RP11-166O4 (Accesion number AC006480; Position: Chr7: 66699524–66859231) and was labeled green .\nFISH analysis showed double fusion signals in 91 out of 100 examined interphase nuclei from white blood cells suggesting an IKZF1–TYW1 fusion gene .", "summary": "We used fluorescence in situ hybridization (FISH), array comparative genomic hybridization (aCGH), RNA sequencing, reverse transcription (RT) and genomic polymerase chain reaction (PCR), as well as Sanger sequencing to investigate a case of pediatric ALL with a normal karyotype. FISH with a commercial PDGFRB breakapart probe showed loss of the distal part of the probe suggesting a breakpoint within the PDGFRB locus. aCGH revealed submicroscopic deletions in chromosome bands 5q32q35.3 (about 30 Mb long, starting within PDGFRB and finishing in the CANX locus), 7q34 (within TCRB), 9p13 (PAX5), 10q26.13 (DMBT1), 14q11.2 (TRAC), and 14q32.33 (within the IGH locus). RNA sequencing detected an in-frame GTF2I-PDGFRB and an out-of-frame IKZF1-TYW1 fusion transcript. Both fusion transcripts were verified by RT-PCR together with Sanger sequencing and interphase FISH. The GTF2I-PDGFRB fusion was also verified by genomic PCR and FISH. The corresponding GTF2I-PDGFRB fusion protein would consist of almost the entire GTF2I and that part of PDGFRB which harbors the catalytic domain of the tyrosine kinase. It would therefore seem to lead to abnormal tyrosine kinase activity in a manner similar to what has been seen for other PDGFRB fusion proteins.", "subclaim_evaluations": [ { "subclaim": "Fluorescence in situ hybridization (FISH) was used to investigate a case of pediatric ALL with a normal karyotype.", "support_label": "supported", "is_refined": false }, { "subclaim": "Array comparative genomic hybridization (aCGH) was used to investigate the case.", "support_label": "supported", "is_refined": false }, { "subclaim": "RNA sequencing was used to investigate the case.", "support_label": "supported", "is_refined": false }, { "subclaim": "Reverse transcription (RT) and genomic polymerase chain reaction (PCR) were used to investigate the case.", "support_label": "supported", "is_refined": false }, { "subclaim": "Sanger sequencing was used to investigate the case.", "support_label": "supported", "is_refined": false }, { "subclaim": "FISH with a commercial PDGFRB breakapart probe showed loss of the distal part of the probe.", "support_label": "supported", "is_refined": false }, { "subclaim": "Array comparative genomic hybridization revealed submicroscopic deletions in chromosome bands 5q32q35.3.", "support_label": "supported", "is_refined": false }, { "subclaim": "Array comparative genomic hybridization revealed submicroscopic deletions in chromosome band 7q34.", "support_label": "supported", "is_refined": false }, { "subclaim": "Array comparative genomic hybridization revealed submicroscopic deletions in chromosome band 9p13.", "support_label": "supported", "is_refined": false }, { "subclaim": "Array comparative genomic hybridization revealed submicroscopic deletions in chromosome band 10q26.13.", "support_label": "supported", "is_refined": false }, { "subclaim": "Array comparative genomic hybridization revealed submicroscopic deletions in chromosome band 14q11.2.", "support_label": "supported", "is_refined": false }, { "subclaim": "Array comparative genomic hybridization revealed submicroscopic deletions in chromosome band 14q32.33.", "support_label": "supported", "is_refined": false }, { "subclaim": "RNA sequencing detected an in-frame GTF2I-PDGFRB fusion transcript.", "support_label": "not_supported", "original_label": "not_supported", "reasoning_audit": "No explicit tags provided.", "is_refined": true }, { "subclaim": "RNA sequencing detected an out-of-frame IKZF1-TYW1 fusion transcript.", "support_label": "supported", "is_refined": false }, { "subclaim": "Both fusion transcripts were verified by RT-PCR.", "support_label": "supported", "is_refined": false }, { "subclaim": "Both fusion transcripts were verified by Sanger sequencing.", "support_label": "supported", "is_refined": false }, { "subclaim": "Both fusion transcripts were verified by interphase FISH.", "support_label": "supported", "is_refined": false }, { "subclaim": "The GTF2I-PDGFRB fusion was also verified by genomic PCR.", "support_label": "supported", "is_refined": false }, { "subclaim": "The GTF2I-PDGFRB fusion was also verified by FISH.", "support_label": "supported", "is_refined": false }, { "subclaim": "The GTF2I-PDGFRB fusion protein would consist of almost the entire GTF2I.", "support_label": "not_supported", "original_label": "not_supported", "reasoning_audit": "No explicit tags provided.", "is_refined": true }, { "subclaim": "The GTF2I-PDGFRB fusion protein would include that part of PDGFRB which harbors the catalytic domain of the tyrosine kinase.", "support_label": "not_supported", "original_label": "not_supported", "reasoning_audit": "No explicit tags provided.", "is_refined": true }, { "subclaim": "The GTF2I-PDGFRB fusion protein would lead to abnormal tyrosine kinase activity.", "support_label": "not_supported", "original_label": "not_supported", "reasoning_audit": "No explicit tags provided.", "is_refined": true }, { "subclaim": "The GTF2I-PDGFRB fusion protein would lead to abnormal tyrosine kinase activity similar to other PDGFRB fusion proteins.", "support_label": "not_supported", "original_label": "not_supported", "reasoning_audit": "No explicit tags provided.", "is_refined": true } ] }, { "id": "multiclinsum_test_354_en.txt", "fulltext": "In august 2018, an 81-year-old caucasian man presented to the emergency department with fever, progressive dyspnea, dry cough and left pleuritic chest pain.\nPatients symptoms started 3 wk ago and worsened progressively.\nHis medical history was consistent with chronic lymphocytic leukemia, initially treated in 2007 with Fludarabine, Cyclophosphamide and Rituximab therapy with chronic lymphocytosis, type 2 diabetes mellitus, hypertension, hyperlipidemia and chronic kidney failure with an eGFR of 28 mL/min/1.73 m2. He reported no smoking or alcohol abuse and used to work as an upholsterer.\nNone.\nPhysical examination revealed fever (38.1°C), tachycardia (105 bpm), peripheral percutaneous oxygen saturation was 100% with 2 liters of oxygen with tachypnea, normal blood pressure and almost abolished left vesicular murmur. Adenopathy, hepatomegaly or splenomegaly were not observed. Cardiovascular and neurologic examination were normal.\nBiology tests revealed neutrophilia (18.7 g/L) and elevated CRP (297 mg/L) consistent with inflammatory response, along with stable lymphocytosis (242 g/L) and anemia (7.8 g/L).\nChest X-ray at admission showed a large left pleural effusion with contralateral tracheal deviation. Complementary computed tomography confirmed a walled-off, loculated left pleural effusion, with right lung parenchyma considered normal.\nFirst bedside pleural puncture showed a citrine exudate (pleural protein 37 g/L, pleural fluid protein to serum ratio 0.61), unfortunately cytological examination was not performed.\nDespite intravenous treatment with cefotaxime, the patient condition worsened with persistence of fever, neutrophilia, and severe hypoxemia appeared. Bacteriological standard culture of the pleural liquid sample was negative, as well as repeated blood cultures. In order to look for a tuberculosis etiology, auramine stained sputum smears and cultures were performed but remained negative. Spot-test for tuberculosis was not performed. Ten days after his admission, because of the uncontrolled large pleural effusion with acute hypoxemic respiratory failure, the patient underwent surgical thoracentesis with evacuation of 2 liters of purulent liquid. We chose surgery instead of repeated pleural drawings, because local sepsis was not controlled nor bacteriologically documented. Pleura was thick and nodular, with white pseudo-membranes. Treatment with metronidazole was added to cefotaxime after the surgery in order to cover anaerobic bacteria. Cytobacteriological examination and cultures of the liquid were negative. Lymphocyte phenotyping ruled out B-cell lymphoma as a complication of his chronic lymphocytic leukemia. Three days after, the patient progressively developed multiple organ failure requiring intensive care unit admission. As no massive transfusion was initiated during surgery and shock was the main matter, fluid overload could not explain the evolution in multiple organ failure. After a slow unfavorable evolution during the ten first days of hospitalization, the patient’s condition worse brutaly three days after surgical thoracocentesis leading to septic shock complicated of multiple organ failure. Despite antibiotherapy with cefepime and amikacin, invasive mechanical ventilation, vasopressor infusion and renal replacement therapy, the patient died of uncontrolled septic shock few hours after ICU admission.\nThe day after, mycobacterial culture of surgical pleural samples yielded Gram-negative bacilli . Rapid identification using matrix-assisted desorption ionization–time of flight mass spectrometry (MALDI-TOF MS; Microflex LT; Bruker Daltonics, Leipzig, Germany) was performed and L. pneumophila was identified. The bacteria were addressed to the National Reference Center of Legionella and molecular typing analysis by sequence-based typing was performed and showed that the strain of L. pneumophila serogroup 1 belonged to Sequence Type 1. Urinary antigen research retrospectively performed on a urine sample of the patient confirmed the presence of L. pneumophila serogroup 1.\nWe believe that chances of super infection or co-infection with another bacterium are scarce. Patient indeed received broad spectrum antibiotics directed against common bacteria causing pleural empyema (including anaerobic bacteria, gram-negative bacillus, streptococci and staphylococci), and repeated standard bacteriological cultures remained negative.\nRetrospectively, our patient presented the following risk factors: Male sex, aged more than 50 years, chronic lymphocytic leukemia with history of immunocompromising treatments, chronic kidney failure, diabetes mellitus and weaned smoking.", "summary": "An 81-year-old man presented to the emergency with a 3 wk dyspnea, fever and left chest pain. His previous medical conditions were chronic lymphocytic leukemia, diabetes mellitus, chronic kidney failure, hypertension and hyperlipidemia, without tobacco use. Chest X-ray and comouted tomography-scan confirmed a large left pleural effusion, which puncture showed a citrine exudate with negative standard bacterial cultures. Despite intravenous cefotaxime antibiotherapy, patient's worsening condition after 10 d led to thoracocentesis and evacuation of 2 liters of pus. The patient progressively developed severe hypoxemia and multiorgan failure occurred. The patient was treated by antibiotherapy with cefepime and amikacin and with adequate symptomatic shock treatment, but died of uncontrolled sepsis. The next day, cultures of the surgical pleural liquid samples yielded L. pneumophila serogroup 1, consistent with the diagnosis of pleural legionellosis.", "subclaim_evaluations": [ { "subclaim": "The patient is an 81-year-old man.", "support_label": "supported", "is_refined": false }, { "subclaim": "He presented with 3 weeks of dyspnea.", "support_label": "supported", "is_refined": false }, { "subclaim": "He had fever.", "support_label": "supported", "is_refined": false }, { "subclaim": "He had left chest pain.", "support_label": "supported", "is_refined": false }, { "subclaim": "He has chronic lymphocytic leukemia.", "support_label": "supported", "is_refined": false }, { "subclaim": "He has diabetes mellitus.", "support_label": "supported", "is_refined": false }, { "subclaim": "He has chronic kidney failure.", "support_label": "supported", "is_refined": false }, { "subclaim": "He has hypertension.", "support_label": "supported", "is_refined": false }, { "subclaim": "He has hyperlipidemia.", "support_label": "supported", "is_refined": false }, { "subclaim": "Chest X-ray showed a large left pleural effusion.", "support_label": "supported", "is_refined": false }, { "subclaim": "Computed tomography confirmed a large left pleural effusion.", "support_label": "supported", "is_refined": false }, { "subclaim": "Thoracentesis showed a citrine exudate.", "support_label": "supported", "is_refined": false }, { "subclaim": "Standard bacterial cultures were negative.", "support_label": "supported", "is_refined": false }, { "subclaim": "He received intravenous cefotaxime.", "support_label": "supported", "is_refined": false }, { "subclaim": "After 10 days, his condition worsened.", "support_label": "supported", "is_refined": false }, { "subclaim": "Thoracocentesis evacuated 2 liters of pus.", "support_label": "supported", "is_refined": false }, { "subclaim": "He developed severe hypoxemia.", "support_label": "supported", "is_refined": false }, { "subclaim": "Multiorgan failure occurred.", "support_label": "supported", "is_refined": false }, { "subclaim": "He was treated with cefepime.", "support_label": "supported", "is_refined": false }, { "subclaim": "He was treated with amikacin.", "support_label": "supported", "is_refined": false }, { "subclaim": "He received adequate symptomatic shock treatment.", "support_label": "supported", "is_refined": false }, { "subclaim": "He died of uncontrolled sepsis.", "support_label": "supported", "is_refined": false }, { "subclaim": "Cultures of surgical pleural fluid yielded L. pneumophila serogroup 1.", "support_label": "supported", "is_refined": false }, { "subclaim": "The diagnosis was pleural legionellosis.", "support_label": "supported", "is_refined": false } ] }, { "id": "multiclinsum_test_659_en.txt", "fulltext": "A 35-year-old female patient arrived at our department complaining of back pain, heart palpitations, and fatigue due to the large size of pericardial mass causing a pressure symptom. No symptoms of hypertension, fever, extrasystoles were found on physical examination, and no arrhythmia or rhythm disturbances were found on the electrocardiography. No previous medical and family history was declared by the patient. A chest X-ray showed that the patient’s cardiothoracic ratio was enlarged and that her cardiophrenic sinus was obscured on the right side (see Fig. ). A transthoracic echocardiography indicated pericardial effusion, tricuspid, and pulmonary insufficiencies and showed a large echogenic mass involving the pericardium beside the right heart. Pericardiocentesis was performed, and a cytologic examination of the bloody pericardial fluid obtained though fine needle aspiration (FNA) showed monotonous cells with oval-spindle vesicular nuclei with less amphophilic cytoplasm, evenly distributed chromatin, and inconspicuous nucleoli that formed groups in hypocellular samples (see Fig. ). Overlapping nuclei were observed locally. During pre-diagnosis, a spindle cell mesenchymal tumor with uncertain malignant potential was considered. Adequate sample cannot be obtained from aspiration for cell block preparation.\nA contrasted CT scan of the chest showed a heterogeneously enhanced lesion measuring 12 cm x 11 cm x 6.5 cm located in the right mid-anterior of the pericardial area (see Fig. ). The mass had a heterogeneous internal structure, creating significant pressure on the right heart and superior vena cava. There was no radiological space between the mass and the right heart, and no significant vascular, cardiac, or thoracic wall invasions were observed. No lymph node involvement was observed in the mediastinal or hilar regions. The trachea, including both main bronchi and bronchial trees, was open. Neither an active infiltrative appearance nor any nodular lesions could not be seen in the lung parenchyma (see Fig. ). All radiological findings were indicative of either a pericardial fibroma or a pericardial sarcoma, both of which were noted in the differential diagnosis. On positron emission tomography (PET)-CT imaging, only the pericardial mass showed increased F-18 fluorodeoxyglucose (FDG) uptake with a maximum standard uptake of 5.3. No lymph node metastasis was detected radiologically.\nAfter the radiological examinations, the pericardial mass was decided to be resected. During thoracotomy, the pericardial mass was found to invade the ventricular wall and main vascular structures, therefore, the mass was resected incompletely. Due to the location, extent and nature of the tumor, debulking surgery was performed and R0 surgery could not be performed. Macroscopically, any palpable lymph node was not detected during the surgery.\nHistopathologically, a spindle cell mesenchymal tumor with infiltrative limited hypercellular fascicular structure containing a small amount of loose myxoid stroma hyalinized, and necrotic areas showing mild to moderate pleomorphism were observed in fragmented mass samples (see Fig. a). A nuclear palisade was noted in the neoplastic cells, and the mitotic rate was 18 mitotic cells per 10 high power fields (see Fig. b). Mesothelioma, fibrosarcoma, a solitary fibrous tumor, leiomyosarcoma, and synovial sarcoma were all included as possibilities in the differential diagnosis. Immunohistochemical staining showed a positive reaction with vimentin, Bcl-2, TLE-1 (see Fig. c), and a negative reaction with pan-cytokeratin, HBME-1, calretinin, CD99, actin, desmin, CD34, STAT6, and S100. The Ki67 proliferation index was increased in the tumor (see Fig. d). A sample was sent to an external center where molecular studies could be performed for genetic analysis, and a real-time polymerase chain reaction (RT-PCR) test detected SYT-SSX1 fusion. With these findings, the patient was given a definitive diagnosed of monophasic synovial sarcoma.\nPostoperative radiotherapy and chemotherapy were advised but refused by the patient at first place. On postoperative 4th month, the patient decided to undergo the oncological therapies, however, a six-week pregnancy was detected, therefore, only radiotherapy was applied due to the enlargement of pericardial mass. The chemotherapy was postponed for one year. After the term delivery, the patient suffered from the respiratory distress due to enlargement of the mass in the pericardial region to 14 cm in diameter, therefore, six cycles of doxorubicin and ifosfamide combination were administered. An emboli in the left main pulmonary artery, a pleural effusion in the right hemithorax, and a metastatic mass in the liver were detected. The patient whose respiratory parameters deteriorated was followed up in the intensive care unit. During this follow-up, the patient, who had myocardial infarction 21 months after the operation, died.", "summary": "The case with back pain, palpitation and weakness, was diagnosed with pericardial effusion and suspicious mass adjacent to right heart in ultrasonography. Computerized tomography showed mass 12 × 11 × 6.5 cm in size, located in right mid-anterior pericardial area, with heterogeneous internal structure, heterogeneously contrasting right heart and prominent pressure on superior vena cava. Cytopathology of pericardial effusion showed monotonous cells with oval-spindle vesicular nuclei, less amphophilic cytoplasm, evenly distributed chromatin and inconspicuous nucleoli. The pericardial mass was resected incompletely, spindle cell mesenchymal tumor with hypercellular fascicular structure and with infiltrative margins, containing a small amount of loose myxoid stroma, occasionally necrotic areas was observed histopathologically. Immunohistochemical positive reaction was for vimentin, Bcl-2, TLE-1. Accordingly, the case was diagnosed with monophasic PSS.", "subclaim_evaluations": [ { "subclaim": "The patient had back pain.", "support_label": "supported", "is_refined": false }, { "subclaim": "The patient had palpitations.", "support_label": "supported", "is_refined": false }, { "subclaim": "The patient had weakness.", "support_label": "supported", "is_refined": false }, { "subclaim": "Ultrasonography showed pericardial effusion.", "support_label": "supported", "is_refined": false }, { "subclaim": "Ultrasonography showed a suspicious mass adjacent to the right heart.", "support_label": "supported", "is_refined": false }, { "subclaim": "CT showed a mass measuring 12 × 11 × 6.5 cm.", "support_label": "supported", "is_refined": false }, { "subclaim": "The mass was located in the right mid-anterior pericardial area.", "support_label": "supported", "is_refined": false }, { "subclaim": "The mass had a heterogeneous internal structure.", "support_label": "supported", "is_refined": false }, { "subclaim": "The mass heterogeneously contrasted the right heart.", "support_label": "supported", "is_refined": false }, { "subclaim": "The mass caused prominent pressure on the superior vena cava.", "support_label": "supported", "is_refined": false }, { "subclaim": "Cytopathology of pericardial effusion showed monotonous cells.", "support_label": "supported", "is_refined": false }, { "subclaim": "The cells had oval-spindle vesicular nuclei.", "support_label": "supported", "is_refined": false }, { "subclaim": "The cells had less amphophilic cytoplasm.", "support_label": "supported", "is_refined": false }, { "subclaim": "The cells had evenly distributed chromatin.", "support_label": "supported", "is_refined": false }, { "subclaim": "The cells had inconspicuous nucleoli.", "support_label": "supported", "is_refined": false }, { "subclaim": "The pericardial mass was resected incompletely.", "support_label": "supported", "is_refined": false }, { "subclaim": "Histopathology showed a spindle cell mesenchymal tumor.", "support_label": "supported", "is_refined": false }, { "subclaim": "The tumor had a hypercellular fascicular structure.", "support_label": "supported", "is_refined": false }, { "subclaim": "The tumor had infiltrative margins.", "support_label": "supported", "is_refined": false }, { "subclaim": "The tumor contained a small amount of loose myxoid stroma.", "support_label": "supported", "is_refined": false }, { "subclaim": "The tumor occasionally had necrotic areas.", "support_label": "supported", "is_refined": false }, { "subclaim": "Immunohistochemical staining was positive for vimentin.", "support_label": "supported", "is_refined": false }, { "subclaim": "Immunohistochemical staining was positive for Bcl-2.", "support_label": "supported", "is_refined": false }, { "subclaim": "Immunohistochemical staining was positive for TLE-1.", "support_label": "supported", "is_refined": false }, { "subclaim": "The case was diagnosed with monophasic PSS.", "support_label": "supported", "is_refined": false } ] }, { "id": "multiclinsum_test_3084_en.txt", "fulltext": "A 66-year-old asymptotic male with hypertension, hyperlipidaemia, and a history of syncope was admitted to the hospital after ambulatory 24 h Holter electrocardiography monitoring, which revealed non-sustained ventricular tachycardia. His physical examination was unremarkable. Electrocardiogram revealed sinus rhythm without any ST-segment changes. 2D echocardiography showed preserved left ventricular ejection fraction of 65%. Non-invasive coronary computed tomography angiography (CCTA) showed 60% stenosis of the LMCA bifurcation with the minimal lumen area of 5 mm2, 40% stenosis in the proximal LAD, and 60% stenosis in the proximal LCx. Invasive coronary angiography confirmed stenosis of the LMCA bifurcation as well as revealed two obstructive stenoses of the second diagonal branch (DB) and the distal LCx. The SYNTAX score was 26, which indicates moderate complexity of coronary artery disease and require careful consideration between PCI and CABG. After the heart team’s (cardiologists, interventional cardiologists, cardiac surgeon) decision and patient’s consent, the complex PCI using DK crush bifurcation stenting technique was planned. Firstly, using the right radial approach, successful PCIs of the distal LCx and the second DB were performed. Secondly, LMCA LAD/LCx procedure was carried out. A 7F (French size) EBU (Extra Back Up, a guiding catheter used to provide maximal support and control during PCI) 3.75 mm guiding catheter was used and two Sion Blue ES (Sion Blue Extra Stiff, a guiding catheter used for high torque control and support) guidewires were placed in the distal segments of LCx and LAD. Then, an Ultimaster Nagomi 3.5/18 mm stent was implanted into the LMCA towards the LCx and partially crushed by a 3.0/15 mm semi-compliant balloon. Subsequently, after rewiring, balloon kissing was performed with a 3.0/15 mm semi-compliant balloon in LCx and a 3.5/15 mm semi-compliant balloon in LAD. Ultimaster Nagomi 4.0/15 mm stent was implanted into the LMCA towards the LAD. Proximal optimization technique (a technique involving inflating a balloon in the proximal part of the larger branch to optimize the opening and ensure better stent apposition and expansion before further stenting of the smaller branch) was performed with a 4.0/8 mm non-compliant balloon and, after rewiring the LCx, re-kissing was performed with a 3.0/15 mm balloon in LCx and a 3.5/15 mm balloon in LAD. Finally, an adequate apposition of LMCA/LCx and LAD stents was confirmed by the intravascular ultrasound monitoring. The final angiography revealed an excellent angiographic result, with optimal stent expansion, lesions covered, and TIMI 3 flow in all coronary arteries. The 1-month follow-up of the patient was uneventful.\n\n", "summary": "We describe a 66-year-old Caucasian male with a risk factor for coronary artery disease, but free of angina, who presented to the hospital after syncope and nsVT diagnosis in the 24 h Holter electrocardiography monitoring. Coronary computed tomography angiography revealed LMCA bifurcation stenosis with concomitant left circumflex artery (LCx) and diagonal branch stenosis. Subsequent coronary angiography confirmed diagnosis. Successful percutaneous coronary intervention (PCI) of bifurcation/distal LMCA disease involving ostium of LAD and LCx has been a challenging procedure.", "subclaim_evaluations": [ { "subclaim": "The patient is a 66-year-old Caucasian male.", "support_label": "not_supported", "original_label": "not_supported", "reasoning_audit": "No explicit tags provided.", "is_refined": true }, { "subclaim": "The patient has a risk factor for coronary artery disease.", "support_label": "supported", "is_refined": false }, { "subclaim": "The patient was free of angina.", "support_label": "supported", "is_refined": false }, { "subclaim": "The patient presented to the hospital after syncope.", "support_label": "supported", "is_refined": false }, { "subclaim": "The patient had a diagnosis of non-sustained ventricular tachycardia.", "support_label": "supported", "is_refined": false }, { "subclaim": "The diagnosis was made by 24 h Holter electrocardiography monitoring.", "support_label": "supported", "is_refined": false }, { "subclaim": "Coronary computed tomography angiography revealed LMCA bifurcation stenosis.", "support_label": "supported", "is_refined": false }, { "subclaim": "Coronary computed tomography angiography showed concomitant left circumflex artery stenosis.", "support_label": "supported", "is_refined": false }, { "subclaim": "Coronary computed tomography angiography showed concomitant diagonal branch stenosis.", "support_label": "supported", "is_refined": false }, { "subclaim": "Subsequent coronary angiography confirmed the diagnosis.", "support_label": "supported", "is_refined": false }, { "subclaim": "Percutaneous coronary intervention was performed.", "support_label": "supported", "is_refined": false }, { "subclaim": "The PCI targeted bifurcation/distal LMCA disease.", "support_label": "supported", "is_refined": false }, { "subclaim": "The PCI involved the ostium of the LAD.", "support_label": "supported", "original_label": "not_supported", "reasoning_audit": "No explicit tags provided.", "is_refined": true }, { "subclaim": "The PCI involved the LCx.", "support_label": "supported", "is_refined": false } ] }, { "id": "multiclinsum_test_2535_en.txt", "fulltext": "A 62-year-old man (175.6 cm 75 kg) was scheduled for sternum closure using the right latissimus dorsi muscle flap for mediastinitis. He had gone CABG using the bilateral internal thoracic arteries 8 months before. He underwent debridement and vacuum-assisted closure (VAC) of the infected wounds 1 month after surgery. Although sternum closure using an omental flap was performed thereafter, debridement and VAC were reintroduced because of infection. His medical history included diabetes mellitus with end-stage diabetic nephropathy. He has been receiving hemodialysis, and the right lower leg amputated for diabetic gangrene. He was receiving linagliptin and mitiglinide calcium hydrate and aspirin. His laboratory data showed renal dysfunction (estimated glomerular filtration rate 6.2 ml/min) and anemia (hemoglobin 9.6 d/dl), but no abnormal coagulation was observed, and the platelet count was 145,000/μl. He also complained of postoperative nausea and vomiting (PONV) probably due to fentanyl after multiple anesthesia histories.\nConsidering the possibility of widespread surgical wound and he was taking aspirin, continuous ultrasound-guided ESPB was planned. Aspirin was continued until the day of surgery. He received no premedication. Standard monitoring and intra-arterial blood pressure monitoring were performed. General anesthesia was induced with propofol 70 mg, fentanyl 250 μg, and rocuronium 60 mg and maintained with 1.5% sevoflurane in an inhaled oxygen concentration of 60% with a total flow of 3 l/min and remifentanil 0.1–0.2 μg/kg/min. After tracheal intubation, he was placed in the left lateral decubitus position. After performing standard skin asepsis, the linear transducer (12 MHz, LOGIQ e; GE Healthcare, Chicago IL), within a sterile sleeve, was positioned on the patient in a transverse orientation and the T6 spinous process image was taken. The transducer was moved right laterally to identify the transverse process of T6 and then rotated 90° to visualize the right transverse process and the erector spinae muscles above it. A continuous nerve block set (Contiplex Tuohy Ultra set; B BRAUN, Melsungen, Germany) with an 18-G, 100-mm Tuohy needle was inserted in-plane in a caudal to cranial direction until contact with the right T6 transverse process was made. After confirming that there was no reverse blood flow, hydrodissection with 2 ml of 0.375% ropivacaine was used to confirm the correct needle tip position. Eighteen milliliters of 0.375% ropivacaine was injected, and a 20-G catheter was advanced through the needle. After injecting 20 ml of 0.375% ropivacaine again from the catheter 55 min after the initial injection, 0.2% ropivacaine was continuously infused at 5 ml/h before the start of surgery. Hemodynamic stability was achieved without the need for an additional bolus administration of fentanyl during surgery. One gram of acetaminophen was intravenously infused 30 min before the end of the operation. There were no other events of note during the operation. The operative time was 5 h and 49 min, and the anesthesia time was 8 h and 2 min.\nAfter extubation in the operating room and admission to the intensive care unit (ICU), the nerve blockade area and Numerical Rating Scale (NRS) were confirmed when sufficient consciousness was reached. Regarding nerve blockade, the cold sign was T2–T8, pinprick was T3–T8, and NRS at rest was 1/10 immediately after surgery. The main pain area was the wound where the right latissimus dorsi muscle flap was collected, but pain of the median sternum wound was not noted. Acetaminophen at 500 mg was administered orally because the NRS temporarily increased to 7/10 due to body movement. However, the NRS at rest was 1–2/10 and that while active was 4/10. For pain during movement, 3 ml of patient-controlled analgesia (PCA) consisting of 0.2% ropivacaine was flushed, and this was performed twice in the ICU. After leaving the ICU 24 h after the operation and being transported to the general ward, pain was not aggravated and the ESPB catheter was removed 56 h after the operation. After removal of the catheter, oral administration of acetaminophen during pain provided good pain control. No ESPB-related complications were observed during ESPB catheter placement or after removal. Regarding PONV, nausea was observed immediately after admission to the ICU and only a single intravenous injection of 10 mg of metoclopramide was administered. Thereafter, the patient had no PONV.", "summary": "A 62-year-old man with mediastinitis was scheduled for sternum closure using a latissimus dorsi muscle flap. He had gone coronary artery bypass grafting and was taking aspirin. After induction of general anesthesia and tracheal intubation, a catheter was inserted for ESPB from the T6 level under ultrasound monitoring and infusion of ropivacaine was started. Tracheal tube was removed in the operating room, cold sense was absent between T2-8, and analgesia was between T3-T8 after uneventful surgery. There were no complications associated with ESPB postoperatively.", "subclaim_evaluations": [ { "subclaim": "The patient is a 62-year-old man.", "support_label": "supported", "is_refined": false }, { "subclaim": "The patient had mediastinitis.", "support_label": "supported", "is_refined": false }, { "subclaim": "The patient was scheduled for sternum closure using a latissimus dorsi muscle flap.", "support_label": "supported", "is_refined": false }, { "subclaim": "The patient had undergone coronary artery bypass grafting.", "support_label": "supported", "is_refined": false }, { "subclaim": "The patient was taking aspirin.", "support_label": "supported", "is_refined": false }, { "subclaim": "General anesthesia was induced.", "support_label": "supported", "is_refined": false }, { "subclaim": "Tracheal intubation was performed.", "support_label": "supported", "is_refined": false }, { "subclaim": "An ESPB catheter was inserted from the T6 level.", "support_label": "supported", "is_refined": false }, { "subclaim": "The ESPB catheter insertion was performed under ultrasound monitoring.", "support_label": "supported", "is_refined": false }, { "subclaim": "Ropivacaine infusion was started.", "support_label": "supported", "is_refined": false }, { "subclaim": "The tracheal tube was removed in the operating room.", "support_label": "supported", "is_refined": false }, { "subclaim": "Cold sense was absent between T2-8.", "support_label": "supported", "is_refined": false }, { "subclaim": "Analgesia was between T3-T8 after surgery.", "support_label": "supported", "is_refined": false }, { "subclaim": "There were no complications associated with ESPB postoperatively.", "support_label": "supported", "is_refined": false } ] }, { "id": "multiclinsum_test_268_en.txt", "fulltext": "A 46-year-old woman had undergone mastectomy for breast cancer (estrogen receptor 2+, progesterone receptor 3+, and HER2 3+) 5 years before presentation and had subsequently remained under observation without any postoperative adjuvant therapy. Multiple lung, liver, and bone metastases were identified in year 3 postoperatively, and systemic chemotherapy was introduced. The chemotherapy regimen included docetaxel, trastuzumab, pertuzumab, and bisphosphonates, and radiotherapy for lumbar spinal bone metastases (20 Gy/5 Fr). However, she developed multiple brain metastases (BM) 1 year later, which were treated with whole-brain radiotherapy (30 Gy/10 Fr) and placement of a ventriculoperitoneal shunt for hydrocephalus. The systemic chemotherapy regimen was subsequently switched to trastuzumab emtansine, but further LM developed, and the patient was referred to our hospital.\nAt the time of referral, Eastern Cooperative Oncology Group (ECOG) performance status was 4, level of consciousness as assessed by Glasgow coma scale score was E3V4M6, and she was suffering from intractable headaches, severe nausea and vomiting, and cerebellar ataxia. T1-weighted gadolinium- enhanced magnetic resonance imaging (MRI) revealed diffuse contrast enhancement of the meninges, mainly in the posterior cranial fossa, with compression of the cerebellum by the significantly thickened meninges [,]. In light of the clinical course, treatment options were limited, and best supportive care was presented as an option.\nHowever, the patient requested further therapy, and given her good karnofsky performance status (KPS), an aggressive treatment strategy was pursued. The first step in the treatment was to relieve intracranial hypertension, and decompression of the posterior cranial fossa was performed . After surgery, headaches, nausea, and vomiting were immediately improved and her performance status improved.\nTreatment with lapatinib at 1250 mg and capecitabine 1200 mg was started on postoperative day 14. As early as 2 weeks later, the diffuse abnormal signal enhancement across her tissues shrunk dramatically on T1-weighted gadolinium- enhanced MRI after starting this new regimen [,]. Further imaging revealed that the LM had almost disappeared on MRI by 2 months of therapy [,]. At present, no recurrence has been observed more than 1 year after the treatment. The patient is continuing to attend our hospital unit for treatment under the same regimen and currently remains well with an ECOG Performance Status 1.", "summary": "We report on a 46-year-old woman with LM from human epidermal growth factor receptor 2 (HER2)-positive breast cancer. She was suffering from intractable headaches, severe nausea and vomiting, and cerebellar ataxia. Contrast-enhanced magnetic resonance imaging (MRI) revealed diffuse enhancement of the meninges, mainly in the posterior cranial fossa, and compression of the cerebellum by the profoundly thickened meninges. The first step in the treatment was decompression of the posterior cranial fossa to relieve intracranial hypertension. After surgery, her symptoms immediately improved. The second step was treatment with lapatinib at 1250 mg and capecitabine 1200 mg, which dramatically improved her symptoms and disappeared diffuse abnormal signal enhancement on MRI.", "subclaim_evaluations": [ { "subclaim": "The patient is a 46-year-old woman.", "support_label": "supported", "is_refined": false }, { "subclaim": "She has leptomeningeal metastasis from HER2-positive breast cancer.", "support_label": "supported", "is_refined": false }, { "subclaim": "She had intractable headaches.", "support_label": "supported", "is_refined": false }, { "subclaim": "She had severe nausea and vomiting.", "support_label": "supported", "is_refined": false }, { "subclaim": "She had cerebellar ataxia.", "support_label": "supported", "is_refined": false }, { "subclaim": "Contrast-enhanced MRI showed diffuse enhancement of the meninges.", "support_label": "supported", "is_refined": false }, { "subclaim": "The meningeal enhancement was mainly in the posterior cranial fossa.", "support_label": "supported", "is_refined": false }, { "subclaim": "The meninges were profoundly thickened.", "support_label": "supported", "is_refined": false }, { "subclaim": "The thickened meninges compressed the cerebellum.", "support_label": "supported", "is_refined": false }, { "subclaim": "The first treatment step was decompression of the posterior cranial fossa.", "support_label": "supported", "is_refined": false }, { "subclaim": "Decompression was performed to relieve intracranial hypertension.", "support_label": "supported", "is_refined": false }, { "subclaim": "Symptoms improved immediately after surgery.", "support_label": "supported", "is_refined": false }, { "subclaim": "The second treatment step was lapatinib at 1250 mg.", "support_label": "supported", "is_refined": false }, { "subclaim": "The second treatment step was capecitabine at 1200 mg.", "support_label": "not_supported", "original_label": "not_supported", "reasoning_audit": "No explicit tags provided.", "is_refined": true }, { "subclaim": "Treatment with lapatinib and capecitabine dramatically improved symptoms.", "support_label": "supported", "is_refined": false }, { "subclaim": "Diffuse abnormal signal enhancement on MRI disappeared after treatment.", "support_label": "supported", "is_refined": false } ] }, { "id": "multiclinsum_test_688_en.txt", "fulltext": "A 48-year-old white man with a medical history of recurrent pneumonitis and therapy-resistant ulcerative colitis over 10 years presented with fever and cough with sputum production for 10 d. He reported resting dyspnea and pain over the right thoracic wall.\nUnder antibiotic therapy with moxifloxacin, no clinical improvement was reported. A chest roentgenogram showed an effaced right costo-phrenic angle and nonvisualization of the right hilar shadow suggestive of right lower lobe collapse .\nBronchoscopy revealed complete occlusion of the right bronchus intermedius due to a smooth-walled vascular mass with intact overlying epithelium. A computed tomography (CT) scan revealed a well-defined round-to-oval, smoothly marginated tumor measuring 43 mm × 56 mm in size located endobronchially in the proximal right main stem bronchus causing complete collapse of the right middle and lower lobe . A PET-CT scan showed a low metabolically active mass in the lower lobe, consistent with a carcinoid tumor, and metabolically active prominent and probably reactive mediastinal and hilar lymph nodes.", "summary": "We report the case of a 48-year-old male who presented with cough, dyspnea, a history of recurrent pneumonitis, and therapy-refractory ulcerative colitis that completely subsided after the resection of a pulmonary carcinoid.", "subclaim_evaluations": [ { "subclaim": "The patient is a 48-year-old male.", "support_label": "supported", "is_refined": false }, { "subclaim": "The patient had cough.", "support_label": "supported", "is_refined": false }, { "subclaim": "The patient had dyspnea.", "support_label": "supported", "is_refined": false }, { "subclaim": "The patient had a history of recurrent pneumonitis.", "support_label": "supported", "is_refined": false }, { "subclaim": "The patient had therapy-refractory ulcerative colitis.", "support_label": "supported", "is_refined": false }, { "subclaim": "The patient's ulcerative colitis completely subsided.", "support_label": "not_supported", "original_label": "not_supported", "reasoning_audit": "No explicit tags provided.", "is_refined": true }, { "subclaim": "The subsidence occurred after the resection of a pulmonary carcinoid.", "support_label": "not_supported", "original_label": "not_supported", "reasoning_audit": "No explicit tags provided.", "is_refined": true } ] }, { "id": "multiclinsum_test_1657_en.txt", "fulltext": "A 36-year-old woman with a 2-month history of abdominal and back pain was referred and admitted to our hospital for treatment. The patient had no history of disease. On physical examination, a hard, elastic, poorly flexible mass was palpable in the right upper abdomen. No signs of obstructive jaundice or abdominal tenderness were identified. Laboratory analysis revealed anemia (hemoglobin = 10.6 g/dL), thrombocytosis (43.9 × 104/μL), and elevation of C-reactive protein (2.71 mg/dl). The remaining laboratory examinations were within normal ranges, including tumor markers α-fetoprotein (AFP), carcinoembryonic antigen (CEA), and cancer antigen (CA)19-9. Abdominal ultrasonography revealed an extensive space-occupying lesion in the right lobe of the liver, 15 cm in diameter, showing a heterogeneous internal component including hemorrhage and hypervascular mural nodule . Contrast-enhanced computed tomography (CT) of the abdomen showed a cystic mass measuring 13 × 14 × 11 cm in the right lobe of the liver with enhanced mural nodule . Magnetic resonance imaging (MRI) of the abdomen showed hyperintense components on T2-weighted imaging, compatible with the hemorrhagic area . Abnormal accumulation was seen on 18F-fluorodeoxyglucose positron emission tomography (FDG-PET) of the liver and lower abdomen . We then planned excision of the tumor and performed hepatectomy of the posterior segment and partial resection of the omentum, which had been detected on FDG-PET. Gross examination of the hepatic tumor showed a massive cystic tumor measuring 18 × 15 cm containing hemorrhagic fluid, and mucinous, hemorrhagic brownish or yellowish multinodular tumors were observed in the extra cystic wall area . The omental tumors were two slightly brownish, nodular tumors measuring 2.1 × 1.3 and 0.3 × 0.3 cm . Microscopically, both hepatic and omental tumors comprised tubular, cystic, or spindle structures of epithelioid cells with clear or eosinophilic cytoplasm . Immunohistochemically, tumor cells were positive for AE1/AE3, EMA, CK19, CK7, CD10, and calretinin , partly or weakly positive for CK5/6, D2-40, vimentin, and WT-1, and negative for HepPer1, chromogranin A, synaptophysin, CEA, inhibin α, MUC1, melan A, HMB45, CA19-9, ER, PgR, CD34, bcl-2, and β-catenin . Ki-67 index was 5–6% . The final pathological diagnosis was multiple low-grade malignant epithelioid mesothelioma. As of the time of writing, 6 months postoperatively, the patient has shown no disease recurrence.\nMalignant mesothelioma commonly arises from the pleura, but can also arise from the peritoneum, pericardium, and tunica vaginalis testis . However, malignant mesothelioma of the liver is extremely rare and coexistence with malignant mesothelioma of the greater omentum has not been addressed in the literature. Mesothelioma of the liver may arise from Glisson’s capsule, the hepatic falciform ligament or fibrous connective tissue, and then expand to the liver parenchyma . To search the literatures, we used key words of intrahepatic, malignant, and mesothelioma and found 12 case reports which have described primary intrahepatic malignant mesothelioma [–] . In detail, these cases involved six men and six women, with a mean age of 58.4 years (range, 41–68 years). Our case represents the youngest female case among these reported cases. Although conventional mesothelioma is frequently associated with asbestos exposure, only 1 case had a clear history of asbestos exposure. Among the remaining 10 cases, 8 cases had no history of asbestos exposure and 3 were not evaluated. One case had a history of viral hepatitis, and 9 cases did not. Mean tumor size was 12.2 cm (range, 3.2–24 cm), and our case showed the third largest mass. Gross finding of the tumor was a cystic mass which is not common, and there was no report of case with cystic tumor ever. This tumor contained hemorrhagic fluid; therefore, we thought that the tumor might have bled and formed cystic mass. In 10 cases, the tumor arose in the right lobe, as in our case, and only one tumor arose in the left lobe. Surgery was performed in 10 cases, and only 1 case received best supportive care, due to systemic lymph node swelling and rupture of the tumor . Pathologically, malignant mesothelioma is classifiable into three subtypes: epithelioid, sarcomatoid, and biphasic. The epithelioid type is the most common type, and tubulopapillary or solid variations can be seen in the tumor . The tumor in our case was also diagnosed as epithelioid type, but showed atypical findings such as solid and tubular, cystic, or spindle components in the tumor, clearly partitioned from normal liver tissue by a fibrous capsule. The tumor showed partial hyalinization, but no necrosis. Typical immunohistochemical features are positive results for calretinin, vimentin, cytokeratin, WT-1, and D2-40 and negative results for CD34, CEA, AFP, and Ber-EP4, as seen in our case . In terms of tumor proliferative activity, Ki-67 index in the typical malignant mesothelioma is 15–20% , but was 5–6% in our case. The tumor was therefore diagnosed as a low-grade malignant tumor, and metastasis was considered unlikely, although a primary malignant omental mesothelioma is also a rare disease. We found only 2 case reports of malignant mesothelioma of the omentum researching with key words of greater omentum, malignant, and mesothelioma [, ]. It was difficult to distinguish multiple tumor from metastatic omental tumor in our case. Multiple malignant mesotheliomas and metastasis of low-grade malignant mesothelioma are both unlikely. The omental tumor cells were positive for AE1/AE3, CK19, CK7, EMA, C D10, and calretinin, partly for CK5/6, D2-40, and vimentin, and negative for HepPer1, chromogranin A, synaptophysin, CEA, inhibin, MUC1, melan A, HMB45, CA19-9, ER, PgR, CD34, bcl-2, and β-catenin that was same findings with hepatic tumor. However, both tumors have fibrous capsule without invasion of tumor cells. Moreover, both tumors had lower proliferated activity and considered to be low-grade malignant tumor. Basing on these pathological findings, we should diagnose the tumors as multiple mesotheliomas, although we are not able to deny a possibility of dissemination. Concerning about the outcome, lymph node relapse has only been reported in 2 cases, and they were alive at 2 or 36 months after relapse without hematogenous metastatic disease [, ]. Our patient remains alive as of 6 months after surgery without relapse.", "summary": "A 36-year-old woman was admitted to our hospital for the evaluation of an elastic hard mass in the right upper abdomen. Abdominal contrast computed tomography showed a cystic mass measuring 13 × 14 × 11 cm in the right liver lobe with enhanced mural nodule. Abnormal accumulation was identified in the liver and lower abdominal area on 18F-fluorodeoxyglucose positron emission tomography. The patient underwent hepatectomy of the posterior segment and partial resection of the omentum. The final pathological diagnosis was low-grade multiple malignant epithelioid mesothelioma based on characteristic immunohistochemical findings. As of 6 months postoperatively, the patient has shown no disease recurrence.", "subclaim_evaluations": [ { "subclaim": "The patient is a 36-year-old woman.", "support_label": "supported", "is_refined": false }, { "subclaim": "She was admitted for evaluation of an elastic hard mass in the right upper abdomen.", "support_label": "supported", "is_refined": false }, { "subclaim": "Abdominal contrast computed tomography showed a cystic mass in the right liver lobe.", "support_label": "supported", "is_refined": false }, { "subclaim": "The mass measured 13 × 14 × 11 cm.", "support_label": "supported", "is_refined": false }, { "subclaim": "The mass had an enhanced mural nodule.", "support_label": "supported", "is_refined": false }, { "subclaim": "18F-fluorodeoxyglucose positron emission tomography showed abnormal accumulation in the liver.", "support_label": "supported", "is_refined": false }, { "subclaim": "18F-fluorodeoxyglucose positron emission tomography showed abnormal accumulation in the lower abdominal area.", "support_label": "supported", "is_refined": false }, { "subclaim": "The patient underwent hepatectomy of the posterior segment.", "support_label": "supported", "is_refined": false }, { "subclaim": "The patient underwent partial resection of the omentum.", "support_label": "supported", "is_refined": false }, { "subclaim": "The final pathological diagnosis was low-grade multiple malignant epithelioid mesothelioma.", "support_label": "supported", "is_refined": false }, { "subclaim": "The diagnosis was based on characteristic immunohistochemical findings.", "support_label": "supported", "is_refined": false }, { "subclaim": "As of 6 months postoperatively, the patient has shown no disease recurrence.", "support_label": "supported", "is_refined": false } ] }, { "id": "multiclinsum_test_723_en.txt", "fulltext": "We report the case of a 2 years and-5-month-old boy admitted in our clinic for fever with the onset 3 days before admission associating abdominal pain and diarrhea within the last 24 hours. The anamnesis did not reveal any possible exposure to COVID-19 infections or other chronic underlying pathologies.\nThe clinical exam at the time of admission revealed influenced general status, bilateral palpebral edema and conjunctivitis, mucocutaneous signs of dehydration, abdominal tenderness at palpation. The patient weighed 15 kilograms.\nThe laboratory test performed on the day of admission pointed out lymphopenia (1560/mm3), thrombocytopenia (108x103/mm3), anemia (hemoglobin – Hb 10.9 g/dL), elevated C-reactive protein – CRP (162 mg/L), erythrocyte sedimentation rate (50 mm/h) and ferritin levels (389.3 ng/mL), hyponatremia (132 mmol/ L), hypopotassemia (3.94 mmol/L), hypertriglyceridemia (476.3 mg/dL), elevated D-dimer (>5 μg/ml), increased troponin (16.6 ng/L) and NT-proBNP (19,831 pg/ml). The rapid urine exam was negative. The chest X-ray, abdominal ultrasound and echocardiography showed no pathological findings. The blood and urine culture were negative. Corroborating the previously mentioned findings we raised the suspicion of pediatric inflammatory multisystem syndrome possibly associated to COVID-19. We performed a RT-PCR test for SARS-CoV-2 infection, but it was negative. Nevertheless, the serology (IgG anti-SARS-CoV-2) for this infection was positive. Thus, established the diagnosis of PIMS-TS.\nWe initiated intravenous immunoglobulin in a dose of 2 g/kg/day associated with empirical antibiotic (ceftriaxone), anticoagulation therapy (low-molecular weight heparin) and symptomatic drugs (antipyretics, antiemetics, and antidiarrheics). In spite of this therapeutic approach, the fever persisted for the following 36 hours with no clinical improvement. Moreover, the laboratory test performed on the 3rd day of admission showed an increase of the CRP value (216.65 mg/L), and the persistence of elevated NT-proBNP (9,884.2 pg/mL) and D-dimer (1,198 ng/mL), associating also hypoalbuminemia (2.45 g/dL). Therefore, we initiated intravenous methylprednisolone (10 mg/kg/day) for 3 days followed by slow tapering and substitutive treatment with human albumin. We also repeated the echocardiography and we found minimal pericardial effusion, slight dilation of the left cavities (left ventricle - LV z score: 1.6, LV sphericity index: 1.66), regional wall motion abnormalities with dyskinesia of the inferior and infero-septal basal segments of the LV. Moreover, the LV systolic dysfunction was affected, with LV ejection fraction of 40%, with mild mitral regurgitation ; but no coronary impairment. Thus, following pediatric cardiologist’s recommendation, we associated angiotensin converting enzyme inhibitors (Lisinopril), Spironolactone and Hydrochlorothiazide. The serial echocardiography performed during the following days of admission revealed the resorption of the pericardial effusion, with improvement of LV function, correlated with decreased serum levels of NT-proBNP (123.1 pg/mL) and troponin (5.2 pg/mL).\nThe patient was discharged on the 11th day of admission without any complaints and most of the laboratory parameters within normal ranges, except of D-dimer. We recommended the continuation of anticoagulant therapy for another week, as well as Lisinopril, Spironolactone and Hydrochlorothiazide for the following 2 weeks.", "summary": "We report the case of a 2 years and-5-month-old boy admitted in our clinic for fever, abdominal pain and diarrhea. The clinical exam at the time of admission revealed influenced gen-eral status, bilateral palpebral edema and conjunctivitis, mucocutaneous signs of dehydration, and abdominal tenderness at palpation. The laboratory tests performed pointed out lymphopenia, thrombocytopenia, anemia, elevated C-reactive protein - CRP, erythrocyte sedimentation rate and ferritin levels, hyponatremia, hypopotassemia, hypertriglyceridemia, elevated D-dimer, in-creased troponin and NT-proBNP. The real-time polymerase chain reaction (RT-PCR) test for SARS-CoV-2 infection was negative, but the serology was positive. Thus, established the diagnosis of PIMS-TS. We initiated intravenous immunoglobulin, empirical antibiotic, anticoagulation therapy and symptomatic drugs. Nevertheless, the clinical course and laboratory parameters worsened, and the 2nd echocardiography pointed out minimal pericardial effusion, slight dilation of the left cavities, dyskinesia of the inferior and septal basal segments of the left ventricle (LV), and LV systolic dysfunction. Therefore, we associated intravenous methylprednisolone, angiotensin converting enzyme inhibitors, spironolactone and hydrochlorothiazide, with outstanding favorable evolution.", "subclaim_evaluations": [ { "subclaim": "The patient is a 2 years and 5-month-old boy.", "support_label": "supported", "is_refined": false }, { "subclaim": "The patient was admitted for fever.", "support_label": "supported", "is_refined": false }, { "subclaim": "The patient was admitted for abdominal pain.", "support_label": "supported", "is_refined": false }, { "subclaim": "The patient was admitted for diarrhea.", "support_label": "supported", "is_refined": false }, { "subclaim": "The clinical exam at admission showed influenced general status.", "support_label": "supported", "is_refined": false }, { "subclaim": "The clinical exam at admission showed bilateral palpebral edema.", "support_label": "supported", "is_refined": false }, { "subclaim": "The clinical exam at admission showed conjunctivitis.", "support_label": "supported", "is_refined": false }, { "subclaim": "The clinical exam at admission showed mucocutaneous signs of dehydration.", "support_label": "supported", "is_refined": false }, { "subclaim": "The clinical exam at admission showed abdominal tenderness at palpation.", "support_label": "supported", "is_refined": false }, { "subclaim": "Laboratory tests showed lymphopenia.", "support_label": "supported", "is_refined": false }, { "subclaim": "Laboratory tests showed thrombocytopenia.", "support_label": "supported", "is_refined": false }, { "subclaim": "Laboratory tests showed anemia.", "support_label": "supported", "is_refined": false }, { "subclaim": "Laboratory tests showed elevated C-reactive protein.", "support_label": "supported", "is_refined": false }, { "subclaim": "Laboratory tests showed elevated erythrocyte sedimentation rate.", "support_label": "supported", "is_refined": false }, { "subclaim": "Laboratory tests showed elevated ferritin levels.", "support_label": "supported", "is_refined": false }, { "subclaim": "Laboratory tests showed hyponatremia.", "support_label": "supported", "is_refined": false }, { "subclaim": "Laboratory tests showed hypokalemia.", "support_label": "supported", "is_refined": false }, { "subclaim": "Laboratory tests showed hypertriglyceridemia.", "support_label": "supported", "is_refined": false }, { "subclaim": "Laboratory tests showed elevated D-dimer.", "support_label": "supported", "is_refined": false }, { "subclaim": "Laboratory tests showed increased troponin.", "support_label": "supported", "is_refined": false }, { "subclaim": "Laboratory tests showed increased NT-proBNP.", "support_label": "supported", "is_refined": false }, { "subclaim": "The RT-PCR test for SARS-CoV-2 was negative.", "support_label": "supported", "is_refined": false }, { "subclaim": "The SARS-CoV-2 serology was positive.", "support_label": "supported", "is_refined": false }, { "subclaim": "The diagnosis of PIMS-TS was established.", "support_label": "supported", "is_refined": false }, { "subclaim": "Intravenous immunoglobulin was initiated.", "support_label": "supported", "is_refined": false }, { "subclaim": "Empirical antibiotic therapy was initiated.", "support_label": "supported", "is_refined": false }, { "subclaim": "Anticoagulation therapy was initiated.", "support_label": "supported", "is_refined": false }, { "subclaim": "Symptomatic drugs were initiated.", "support_label": "supported", "is_refined": false }, { "subclaim": "The clinical course worsened.", "support_label": "supported", "is_refined": false }, { "subclaim": "The second echocardiography showed minimal pericardial effusion.", "support_label": "supported", "is_refined": false }, { "subclaim": "The second echocardiography showed slight dilation of the left cavities.", "support_label": "supported", "is_refined": false }, { "subclaim": "The second echocardiography showed dyskinesia of the inferior and septal basal segments of the left ventricle.", "support_label": "supported", "is_refined": false }, { "subclaim": "The second echocardiography showed left ventricular systolic dysfunction.", "support_label": "supported", "is_refined": false }, { "subclaim": "Intravenous methylprednisolone was added.", "support_label": "supported", "is_refined": false }, { "subclaim": "Angiotensin converting enzyme inhibitors were added.", "support_label": "supported", "is_refined": false }, { "subclaim": "Spironolactone was added.", "support_label": "supported", "is_refined": false }, { "subclaim": "Hydrochlorothiazide was added.", "support_label": "supported", "is_refined": false }, { "subclaim": "The clinical evolution was favorable.", "support_label": "supported", "is_refined": false } ] }, { "id": "multiclinsum_test_855_en.txt", "fulltext": "A 14-year-old male patient came to our clinic presenting a traumatic crown fracture of the permanent, maxillary right central incisor .\nThe patient had preserved the broken fragment in saline solution and it was checked for goodness of adaptation to the tooth .\nTo lessen the ordeal for the already traumatized young patient, we decided to treat him using Er:YAG and Nd:YAG lasers we had at hand at our practice (Fidelis III Plus; Fotona, Ljubljana, Slovenia). Due to the patient’s age, an informed consent form for the procedure was signed by his parents.\nThe trauma had left the pulp exposed ; our first decision was to perform Nd: YAG laser (SP mode, 4 W, 40 Hz, 300 μm contact fiber) pulp capping .\nWe then proceeded to use the same Er:YAG device with a different wavelength (SSP mode, 200 mJ, 10 Hz, quasi-contact tip-less handpiece) to prepare the bonding surfaces of both the fragment and the tooth .\nThe same surfaces were further prepared with orthophosphoric acid ( and ); bonding agent was applied, and flow composite resin was used to replace the fragment ( and ).\nFor esthetic purposes, we prepared the borderline area surface with the Er:YAG laser before applying orthophosphoric acid and flow composite resin once more .\nNo form of anesthesia was required nor requested by the patient. Follow-up visits performed after one, three, six, twelve, and sixteen months demonstrated the vitality of the tooth .", "summary": "A 14-year-old patient who came to our clinic with a traumatic crown fracture of the permanent, right central incisor is described. The patient had preserved the fragment that had broken off into his mouth and it was rebonded to the tooth using lasers (LightWalker device; Fotona, Ljubljana, Slovenia) with the following parameters: Er:YAG, SSP mode; 200 mJ; 10 Hz; quasi-contact tipless handpiece; Nd:YAG, SP mode; 4 W; 40 Hz; 300 μm contact fiber. The whole procedure was performed without the need for anesthesia.", "subclaim_evaluations": [ { "subclaim": "The patient is 14 years old.", "support_label": "supported", "is_refined": false }, { "subclaim": "The patient had a traumatic crown fracture of the permanent, right central incisor.", "support_label": "supported", "is_refined": false }, { "subclaim": "The patient had preserved the fragment that had broken off into his mouth.", "support_label": "supported", "is_refined": false }, { "subclaim": "The fragment was rebonded to the tooth using lasers.", "support_label": "supported", "is_refined": false }, { "subclaim": "The lasers used were from the LightWalker device.", "support_label": "not_supported", "original_label": "not_supported", "reasoning_audit": "No explicit tags provided.", "is_refined": true }, { "subclaim": "The device was manufactured by Fotona.", "support_label": "supported", "is_refined": false }, { "subclaim": "The device is based in Ljubljana, Slovenia.", "support_label": "supported", "is_refined": false }, { "subclaim": "The Er:YAG laser was used in SSP mode.", "support_label": "supported", "is_refined": false }, { "subclaim": "The Er:YAG laser had a pulse energy of 200 mJ.", "support_label": "supported", "is_refined": false }, { "subclaim": "The Er:YAG laser had a frequency of 10 Hz.", "support_label": "supported", "is_refined": false }, { "subclaim": "A quasi-contact tipless handpiece was used for the Er:YAG laser.", "support_label": "supported", "is_refined": false }, { "subclaim": "The Nd:YAG laser was used in SP mode.", "support_label": "supported", "is_refined": false }, { "subclaim": "The Nd:YAG laser had a power of 4 W.", "support_label": "supported", "is_refined": false }, { "subclaim": "The Nd:YAG laser had a frequency of 40 Hz.", "support_label": "supported", "is_refined": false }, { "subclaim": "A 300 μm contact fiber was used for the Nd:YAG laser.", "support_label": "supported", "is_refined": false }, { "subclaim": "The procedure was performed without the need for anesthesia.", "support_label": "supported", "is_refined": false } ] }, { "id": "multiclinsum_test_1013_en.txt", "fulltext": "A 15 year old Caucasian female was transferred from a secondary care paediatric unit. She presented with a two-day history of progressive dyspnoea, cough and palpitations on a background of recent onset arthralgia, alopecia and oral ulceration. Clinical examination revealed hypertension (blood pressure 170/110 mmHg), pallor with a malar rash, symmetrical polyarthritis of the interphalangeal and metacarpophalangeal joints, alopecia and oral ulceration.\nInvestigations revealed normocytic anaemia, haemoglobin 95 g/l (normal 120-160 g/l), lymphopaenia, lymphocytes 0.9 × 109/l (normal 1.2–5.2 × 109/l)), elevated inflammatory markers with an erythrocyte sedimentation rate (ESR) of 77 mm/hr. (normal 1-9 mm/hr) and c-reactive protein (CRP) of 38 mg/l (normal < 10 mg/l) and moderately impaired renal function with urea 14.4 mmol/l (normal 2.0–6.0 mmol/l), creatinine 154 μmol/l (normal 30-90 μmol/l). Coagulation screen showed a slightly prolonged prothrombin time (PT) of 13 s (normal 10.2–12.0 s) but was otherwise normal. Albumin was low (28 g/l, normal 36-50 g/l) and liver function tests were normal. Microscopic haematuria and proteinuria were present with an elevated urine albumin:creatinine ratio of 1217 mg/mmol (normal < 3.4 mg/mmol). Antinuclear antibody titres were strongly positive with a titre of 1:160, speckled pattern. Anti double-stranded DNA was positive with a titres of > 379 IU/ml (normal 0-10 IU/ml) and positive Crithidia assay >/= 1:160. Anti-Smith and anti-RNP antibodies were both positive with titres of > 480 U/ml (normal 0–5.0 U/ml) and > 240 U/ml (normal 0-5 U/ml) respectively. There was marked hypocomplementaemia with C3 0.44 g/l (normal 0.7–1.7 g/l), C4 0.06 g/l (normal 0.1–0.7 g/l) and absent CH100 classical and alternative pathway components. Antiphospholipid, anti-SSA and anti-SSB antibodies were all negative. Chest x-ray showed bilateral pleural effusions and cardiomegaly with a cardiothoracic ratio of 0.67. Initial echocardiography showed a large pericardial effusion with diastolic compression of the right atrium and ventricle suggestive of cardiac tamponade. The left ventricle was dilated with an ejection fraction of 25% and there was mild mitral, tricuspid and aortic valvular regurgitation. Treatment was commenced with high-dose intravenous methylprednisolone (30 mg/kg/dose, maximum dose of 1 g) and diuretics and immediate transfer to a tertiary paediatric intensive care unit was arranged.\nOn admission to the intensive care unit she had developed periorbital oedema and ascites with worsening dyspnoea and reduced oxygen saturation. Echocardiography revealed a large pericardial effusion, oedematous myocardium and valvulitis with an ejection fraction of 13% with no evidence of tamponade (see Fig. ). Renal function deteriorated further with a creatinine increase to 270 μmol/l (normal range 30-90 μmol/l) and the patient became anuric. Intermittent positive pressure ventilation, inotropic support, plasma exchange and haemodialysis were required. High-dose intravenous methylprednisolone was continued for 3 days and then changed to oral prednisolone at 1 g/kg/day. Cyclophosphamide was commenced at a dose of 850 mg/m2 on day four of admission due to severe renal impairment and ongoing need for haemodialysis and multiorgan involvement.\nFollow-up echocardiography showed normalisation of function by day five of admission with a small pericardial effusion as the only persistent abnormality. Renal biopsy revealed grade 4 lupus nephritis. The patient was discharged from the intensive care unit on day seven of admission and subsequently discharged from the hospital on day fourteen. Treatment at discharge included a weaning dose of prednisolone, hydroxychloroquine, enalapril and carvedilol. Cyclophosphamide treatment was continued monthly for a total of six doses after which the patient was maintained on further immunosuppression. Remission has been maintained with mycophenolate mofetil and hydroxychloroquine over the past 2 years.", "summary": "We report a case of jSLE in a 15 year old Caucasian female presenting with an acute episode of pancarditis and multiorgan dysfunction who was successfully treated with systemic corticosteroids and cyclophosphamide.", "subclaim_evaluations": [ { "subclaim": "The patient is a 15 year old female.", "support_label": "supported", "is_refined": false }, { "subclaim": "The patient is Caucasian.", "support_label": "supported", "is_refined": false }, { "subclaim": "The patient has juvenile systemic lupus erythematosus.", "support_label": "supported", "is_refined": false }, { "subclaim": "The patient presented with an acute episode of pancarditis.", "support_label": "supported", "is_refined": false }, { "subclaim": "The patient had multiorgan dysfunction.", "support_label": "supported", "is_refined": false }, { "subclaim": "The patient was treated with systemic corticosteroids.", "support_label": "supported", "is_refined": false }, { "subclaim": "The patient was treated with cyclophosphamide.", "support_label": "supported", "is_refined": false }, { "subclaim": "The treatment was successful.", "support_label": "supported", "is_refined": false } ] }, { "id": "multiclinsum_test_3016_en.txt", "fulltext": "A 53-year-old man, who was morbidly obese with a BMI of 75 kg/m2, presented with shortness of breath (SOB) and hypercapnia. He had never smoked but had a history of hypertension and severe obstructive sleep apnea with an apnea-hypopnea index (AHI) >30 per hour. There was no known family history of cardiac disease, and the patient did not have a history of syncope.\n\nOn examination, his blood pressure was 132/83 mmHg, and he had a regular pulse of 98 bpm, a respiratory rate of 20 breaths/minute, a temperature of 98.7°F, with oxygen saturation (SaO2) of 88% on room air. His heart sounds were normal without murmurs. Lung auscultation showed reduced but clear breath sounds, and mild lower limb edema was present.\n\nBlood gases showed a pH of 7.31, PaO2 of 57 mmHg, a PaCO2 of 61 mmHg, and a SaO2 of 86% on room air. Serum bicarbonate was 30 mmol/L, brain natriuretic peptide (BNP) 160 pg/ml, troponin 0.030 ng/ml, and thyroid function tests were normal. An electrocardiogram (ECG) showed normal sinus rhythm with a rate of 95 beats/min, a normal electrical axis with good R wave progression in the precordial leads. No epsilon waves were seen in the precordial leads.\n\nPulmonary function tests showed no obstruction or restriction with a normal diffusing capacity of the lungs for carbon monoxide (DLCO) and normal total lung capacity (TLC). The patient had a reduced forced expiratory volume in one second (FEV1) and forced vital capacity (FVC) with a normal FEV1/FVC ratio, which are commonly seen with obesity hypoventilation syndrome (OHS).\n\nChest computed tomography (CT) showed normal lung parenchyma without pulmonary embolism. Two-dimensional transthoracic echocardiogram (TTE) showed normal left ventricular function and a dilated right ventricle (RV) with a flattened septal wall (1.3 cm in diameter), moderate tricuspid regurgitation, an estimated right ventricular systolic pressure of 55–60 mmHg, right and left atrial dilatation, mild concentric left ventricular hypertrophy, and a left ventricular ejection fraction of 50%. The right ventricle was severely dilated and dysfunctional. There was moderate tricuspid regurgitation (max. velocity 303 cm/sec) with an estimated right ventricular systolic pressure (RVSP) of 55–60 mmHg. Pulse-wave tissue Doppler imaging (TDI) of the anterior and posterior mitral annulus showed abnormal left ventricle relaxation. The patient was discharged on continuous positive airway pressure (CPAP) and oxygen at night, and as needed during the day.", "summary": "Patient: Male, 53\n\nFinal Diagnosis: Right ventricular dysfunction secondary to obesity hypoventilation syndrome\n\nSymptoms: Shortness of breath\n\nMedication: —\n\nClinical Procedure: Echocardiogram (TTE)\n\nSpecialty: Cardiology\n\nA 53-year-old man, who was morbidly obese with a BMI of 75 kg/m2, presented with shortness of breath (SOB) and hypercapnia. He had never smoked but had a history of severe OSA and hypertension. On examination, the patient was obese with normal lung auscultation and mild pitting edema of the lower extremities. A spiral computed tomography (CT) angiogram showed no evidence of pulmonary embolism or interstitial lung disease. Pulmonary function testing showed no obstructive airway disease and a normal diffusion capacity. Two-dimensional transthoracic echocardiogram (TTE) showed normal left ventricular function and a dilated right ventricle (RV) with a flattened septal wall, moderate tricuspid regurgitation, and an estimated right ventricular systolic pressure of 55–60 mmHg. The patient was discharged on continuous positive airway pressure (CPAP) and oxygen at night, and as needed during the day.", "subclaim_evaluations": [ { "subclaim": "The patient is a 53-year-old man.", "support_label": "supported", "is_refined": false }, { "subclaim": "The patient is morbidly obese with a BMI of 75 kg/m2.", "support_label": "supported", "is_refined": false }, { "subclaim": "The patient presented with shortness of breath.", "support_label": "supported", "is_refined": false }, { "subclaim": "The patient had hypercapnia.", "support_label": "supported", "is_refined": false }, { "subclaim": "The patient had a history of severe obstructive sleep apnea.", "support_label": "supported", "is_refined": false }, { "subclaim": "The patient had a history of hypertension.", "support_label": "supported", "is_refined": false }, { "subclaim": "On examination, the patient was obese.", "support_label": "supported", "is_refined": false }, { "subclaim": "A spiral CT angiogram showed no evidence of pulmonary embolism.", "support_label": "supported", "is_refined": false }, { "subclaim": "A spiral CT angiogram showed no evidence of interstitial lung disease.", "support_label": "not_supported", "original_label": "not_supported", "reasoning_audit": "No explicit tags provided.", "is_refined": true }, { "subclaim": "Pulmonary function testing showed no obstructive airway disease.", "support_label": "supported", "is_refined": false }, { "subclaim": "Pulmonary function testing showed a normal diffusion capacity.", "support_label": "supported", "is_refined": false }, { "subclaim": "A transthoracic echocardiogram showed a dilated right ventricle.", "support_label": "supported", "is_refined": false }, { "subclaim": "A transthoracic echocardiogram showed a flattened septal wall.", "support_label": "supported", "is_refined": false }, { "subclaim": "A transthoracic echocardiogram showed moderate tricuspid regurgitation.", "support_label": "supported", "is_refined": false }, { "subclaim": "The estimated right ventricular systolic pressure was 55–60 mmHg.", "support_label": "supported", "is_refined": false }, { "subclaim": "The final diagnosis was right ventricular dysfunction secondary to obesity hypoventilation syndrome.", "support_label": "supported", "is_refined": false }, { "subclaim": "The patient was discharged on continuous positive airway pressure.", "support_label": "supported", "is_refined": false }, { "subclaim": "The patient was discharged on oxygen at night.", "support_label": "supported", "is_refined": false } ] }, { "id": "multiclinsum_test_5_en.txt", "fulltext": "A 24-year-old Sundanese primigravid woman was referred from a peripheral hospital at 38 weeks of gestation due to her deteriorating condition. She presented initially for 5 days of high grade fever, retro-orbital pain, and a blood examination which revealed thrombocytopenia, elevated liver enzymes, and a positive immunoglobulin M (IgM) and immunoglobulin G (IgG) dengue serology. She was diagnosed as having dengue fever in pregnancy and treated with fluid administered intravenously and antipyretics. However, her condition started to worsen on day five of hospitalization with repeated bouts of vomiting and she became lethargic. Her weight was 45 kg and her antenatal history did not reveal hypertension, pre-eclampsia, coagulation abnormalities, or epilepsy.\nDuring her transport, she received 10 liters of oxygen by non-rebreathing mask and had experienced two episodes of generalized tonic–clonic seizure, each lasting less than 1 minute which terminated with 10 mg diazepam administered intravenously. On admission to our ICU, she was responsive only to pain with a blood pressure of 92/76 mmHg, heart rate 124/minute, respiratory rate 30/minute, body temperature 36.6 °C, and oxygen saturation of 95%. A physical examination revealed diffuse rales on both lungs with cold and clammy extremities. Her chest X-ray revealed marked bronchovascular marking on her left and right basal lung regions . Arterial blood gas analysis revealed an acute metabolic alkalosis: pH 7.510, partial pressure of oxygen in arterial blood (PaO2) 166 mmHg, partial pressure of carbon dioxide in arterial blood (PaCO2) 41.3 mmHg, bicarbonate (HCO3\n-) 33.0 mmol/L, and base excess (BE) 9.3 mmol/L. An initial diagnosis of dengue encephalitis, and dengue shock syndrome with acute pulmonary edema was made.\nShe was immediately intubated and placed on mechanical ventilation using adaptive support ventilation mode with the following settings: minute ventilation of 4.5 L, positive end-expiratory pressure (PEEP) 5 cmH2O, and fraction of inspired oxygen (FiO2) of 50% and received continuous sedation under morphine and midazolam infusion. During anesthesia induction, her blood pressure dropped to 60/40 mmHg and a fluid bolus of 300 mL normal saline was given to which she responded. Arterial blood gas analyses taken 2 hours post-intubation with a FiO2 0.7 were as follows: pH 7.475, PaO2 159.1 mmHg, PaCO2 32.1 mmHg, HCO3\n- 24.2 mmol/L and BE 1.1 mmol/L. Another important event included traumatic gum bleeding from biting during her seizure episode which took 1 hour to attain hemostasis, and insertion of a nasogastric tube which yielded 100 mL of dark brown fluid.\nOn day 1, hematologic results revealed hemoglobin (Hgb) of 11.7 g/dL (normal range, N, 11.70 to 15.50 g/dL), hematocrit (Hct) of 36.80% (N, 35.00 to 47.00), and white cell count (WBC) of 10,430/mm3 (N, 3600 to 11,000/ mm3) with 53% neutrophil predominance and 35% lymphocytes. Her platelet (Plt) count was 25,000/uL (N, 150,000 to 440,000), prothrombin time (PT) 10.40 seconds (N, 9.4 to 11.3) with an international normalized ratio (INR) of 1.00, activated partial thromboplastin time (aPTT) of 48.70 (N, 31 to 45 seconds), and a slightly elevated D-dimer of 1.91 ng/mL (N, 0.00 to 0.30). Her bilirubin levels were normal, she had an alanine aminotransferase (ALT) level of 116 U/L (N, 0 to 55), aspartate transaminase (AST) of 359 U/L (N, 5 to 34), urea of 49.0 mg/dL (N, <50), creatinine of 0.85 mg/dL (N, 0.5 to 1.1), lactic acid of 4.7 mmol/L (N, <0.6 to 2.2) and procalcitonin of 0.25 ng/mL (N, <0.15). Her urine was tinted red and complete analysis revealed the presence of slight proteinuria (100 mg/dL) and occult blood (200 cells/uL). Cardiotocography (CTG) monitoring revealed a fetal heart rate of 177 beats per minute (bpm) with no uterine contractions.\nOn day 2, a routine CTG monitoring revealed fetal distress which prompted an emergency cesarean section. She received 500 mL fresh frozen plasma (FFP) before being rushed for cesarean section under general anesthesia. Intraoperative bleeding was 500 mL, an intra-abdominal drain was placed and she received 460 mL of packed red cell (PRC), intraoperatively. A 2.1 kg baby girl was delivered with an appearance, pulse, grimace, activity and respiration (APGAR) score of 4/7. The baby was intubated and transferred to our neonatal ICU (NICU) due to hypoventilation. Our patient was transferred back to ICU and fundal height was noted at the level of umbilicus with good contractions.\nOn day 3, blood clots were seen oozing from her vagina and a vaginal exploration evacuated 200 mL of blood. The intra-abdominal drain collected 50 mL/24 hours of hemoserous fluid and hematologic results revealed Hgb 5.9 g/dL, Hct 18.20%, and Plt 141,000/uL. Upon this substantial drop, 680 mL of PRC, 210 mL of FFP, and 2 units of thrombocyte concentrate apheresis (TCA) were given. Her vital parameters were stable and she remained sedated. A follow-up chest radiography revealed improved clearance of vascular markings on both lung fields confirmed by vesicular lung sounds and a normal acid-base balance with a PaO2/FiO2 of 600 .\nOn day 4, a follow up hematologic examination revealed Hgb 6.96 g/dL, Hct 20.16%, WBC 10,660/mm3, Plt 98,630/uL, albumin 2.63 g/dL, fibrinogen 140 mg/dL (N, 300 to 600), PT 10.90 seconds, and a prolonged aPTT of 56.90 seconds. The intra-abdominal drain collected 450 mL/24 hours of hemoserous fluid and her lower abdomen was noted to be slightly distended. Thereafter, another 230 mL of PRC, 240 mL of FFP, and 2 units of thrombocyte concentrate (TC) was transfused.\nOn day 5, 3 days post-cesarean section, our patient became tachycardic with a blood pressure of 80/60 mmHg, which prompted the use of norepinephrine at 0.08 μg/kg/minute. Uterine contractions were adequate with normal colored lochia, but her lower abdomen appeared distended as before. The intra-abdominal drain collected 360 mL/24 hours of hemoserous fluid and laboratory results were as follow: Hgb 5.90 g/dL, Hct 17.80%, WBC14,020/mm3, Plt 107,000/uL, and albumin of 2.26 g/dL. She was given 20% albumin infusion, 230 mL of PRC, and 220 mL of FFP.\nOn day 6, she remained tachycardic and her mentation did not improve despite stopping sedation. At this time, her lower abdomen appeared more distended and abdominal guarding was noted upon palpation. The intra-abdominal drain had collected 850 mL/24 hours of hemoserous fluid. An urgent blood workup revealed a drop in Hgb to 4.20 g/dL, Hct 12.50%, WBC 10,160/mm3, Plt 84,000/uL, PT 10.40 seconds, aPTT 49.50 seconds, and a spiked D-dimer level (20.25 ug/mL). An emergent ultrasound revealed free fluid on her lower abdominal region which required her to be rushed for an exploratory laparotomy. The procedure evacuated 2000 mL of blood intra-abdominally, and she received 640 mL of PRC and 500 mL FFP, intraoperatively.\nOn day 7, her hematologic examination revealed Hgb 9.60 g/dL, Hct 28.50%, WBC 8,150/mm3, Plt 67,000/uL, normalized coagulation profile, and a lowered D-dimer level (13.98 ug/mL). One unit of TC was transfused and norepinephrine infusion was tapered down with strict vital sign monitoring. Sedation was stopped and her mentation greatly improved. A follow-up chest radiograph revealed clear lung fields and she was placed on a spontaneous breathing trial which was successful and she was later extubated.\nOn day 8, an additional 230 mL PRC was given and her hematologic examination revealed Hgb 11.50 g/dL, Hct 34.40%, and Plt 83,000/uL. Aside from transfusions and vasopressors, she received meropenem 1 gram every 8 hours, early enteral nutrition of 1000 kcal/24 hours, gastric acid prophylaxis agent, gastric motility agents, and anticonvulsants. She was transferred to our general ward on day 8 and discharged from our hospital on day 11, uneventfully. Her neonate was extubated on day 2 of her NICU stay, after complete recovery from sedative drugs in utero and discharged home at day 5 without any negative sequel .", "summary": "A 24-year-old primigravid Sundanese woman presented to our intensive care unit due to acute pulmonary edema secondary to massive plasma leakage caused by severe dengue. She tested positive for both immunoglobulin G and immunoglobulin M dengue serology indicating she had secondary dengue infection, which placed her at risk for an exaggerated cytokine response as was evident clinically. She had to undergo an emergency cesarean section which was later complicated by rebleeding and hemodynamic instability due to an atypical defervescence period. She was successfully managed by multiple blood transfusions and was discharged from our intensive care unit on day 8 without any negative sequel.", "subclaim_evaluations": [ { "subclaim": "The patient is a 24-year-old primigravid Sundanese woman.", "support_label": "supported", "is_refined": false }, { "subclaim": "She presented to the intensive care unit due to acute pulmonary edema.", "support_label": "supported", "is_refined": false }, { "subclaim": "The pulmonary edema was secondary to massive plasma leakage.", "support_label": "supported", "is_refined": false }, { "subclaim": "The plasma leakage was caused by severe dengue.", "support_label": "supported", "is_refined": false }, { "subclaim": "She tested positive for immunoglobulin G dengue serology.", "support_label": "supported", "is_refined": false }, { "subclaim": "She tested positive for immunoglobulin M dengue serology.", "support_label": "supported", "is_refined": false }, { "subclaim": "The positive serology indicated a secondary dengue infection.", "support_label": "not_supported", "original_label": "not_supported", "reasoning_audit": "No explicit tags provided.", "is_refined": true }, { "subclaim": "She had an emergency cesarean section.", "support_label": "supported", "is_refined": false }, { "subclaim": "The cesarean section was complicated by rebleeding.", "support_label": "supported", "is_refined": false }, { "subclaim": "The rebleeding was due to an atypical defervescence period.", "support_label": "not_supported", "original_label": "not_supported", "reasoning_audit": "No explicit tags provided.", "is_refined": true }, { "subclaim": "She was managed by multiple blood transfusions.", "support_label": "supported", "is_refined": false }, { "subclaim": "She was discharged from the intensive care unit on day 8.", "support_label": "supported", "is_refined": false }, { "subclaim": "She had no negative sequel at discharge.", "support_label": "supported", "is_refined": false } ] }, { "id": "multiclinsum_test_357_en.txt", "fulltext": "The patient described is a 28-year-old man with a history of hypertension who initially presented to the ophthalmology department with a 2-year history of progressive, bilateral vision loss. Findings on exam included poor visual acuity, bilateral optic atrophy, reduced foveal threshold, and nonspecific inferior defects. Fundoscopic exam at this time revealed optic disc pallor and a cup-to-disc ratio of 0.3 bilaterally. Given these findings, the patient was subsequently referred to the department of neurology for evaluation of possible MS. Brain MRI revealed T2 FLAIR hyperintense lesions involving the body of the corpus callosum and the periventricular white matter without contrast enhancement, suggestive of demyelinating plaques . CSF testing showed normal protein and cells (0 WBC/mm3, 17 RBC/mm3, 33 mg/dL protein, and 66 mg/dL glucose) along with elevated IgG index and 4 CNS specific oligoclonal bands, strongly increasing the suspicion for MS. MRI of the spine showed no additional lesions. Serological testing for MS mimics was largely unrevealing except for serum copper which was marginally low at 66 ug/dl (normal range 72–166 ug/dl).\nThree months after the diagnosis of MS, the patient presented to an outside hospital with a severe right-sided headache and he was referred to our hospital for further evaluation secondary to imaging demonstrating hydrocephalus and intracranial mass. Of note, the patient had not begun treatment for MS at the time of his hospital admission. At time of presentation, the patient was alert and in no apparent distress. The patient characterized the headache as constant for the past month, and worsened in the week before presentation. He denied any vomiting or nausea and his neurological examination was unremarkable. No upper motor neuron findings or visual field deficits were present at the time of examination. Fundoscopic exam showed no relative afferent pupillary defect. MRI of his brain demonstrated an intraventricular mass located in the posterior third ventricle, obstructive hydrocephalus and worsening of corpus callosum and periventricular T2 hyperintense lesions . An endoscopic third ventriculostomy was successfully performed to treat hydrocephalus and a biopsy was taken of the mass for pathological evaluation.\nTwo small biopsy specimens were submitted for examination. The tumor contained solid sheets of polygonal cells of moderate size and centrally located nuclei. The cytoplasm was pale in some areas [ and ] but was more eosinophilic in other areas. The nuclei were moderately sized and showed a limited variation in size. Prominent nucleoli were noted in many of the tumor cells [Arrow in and ] and were best appreciated in the cytologic preparation obtained during intraoperative consultation. On immunohistochemistry with Ki67, an average labeling index of about 30% was demonstrated. The tumor cells were positive for OCT3/4 , CD117 (c-kit) , placental alkaline phosphatase, cytokeratin AE1/AE3, and cytokeratin 7. The tumor cells were negative for H3 K27M , glial fibrillary acidic protein, Olig2, IDH1-R132H, synaptophysin, Sox10, Melan-A, CD30, thyroid transcription factor 1, and thyroglobulin. The tumor cells were also positive for BAF47 (INI1) indicating no loss of INI1 gene. A diagnosis of germinoma was made based on these characteristics.\nThe patient’s neurologic exam was normal postoperatively and he was discharged home after a 2-day hospital stay. Two months after surgery, the patient was started on carboplatin + etoposide to attempt cytoreduction before radiation therapy to treat intracranial germinoma. Interestingly, brain MRI 4 months after surgery showed resolution of hydrocephalus, periventricular T2 hyperintense changes (thought to possibly be related to trans-ependymal flow initially) and decrease in size of corpus callosum plaques . To rule out paraneoplastic optic neuritis, serum studies were performed and common markers for the disease, anti-CRMP-5, and anti-amphiphysin, were both negative. At the time of this manuscript, the patient had not undergone adjuvant radiation treatment nor started disease modifying treatment for MS as this was held secondary to initial focus on oncologic treatment after discussion among the patient’s treating physicians.", "summary": "A 28-year-old man presented initially with bilateral optic neuritis, manifesting as persistently worsening vision for 2 years, and demyelinating plaques identified within the corpus callosum on magnetic resonance imaging. Initial work-up, in addition to clinical presentation, led to diagnosis of MS. Three months following the diagnosis of MS, the patient then presented with obstructive hydrocephalus due to a newly diagnosed intraventricular mass. The patient underwent an endoscopic third ventriculostomy and biopsy which confirmed diagnosis of CNS germinoma.", "subclaim_evaluations": [ { "subclaim": "The patient is a 28-year-old man.", "support_label": "supported", "is_refined": false }, { "subclaim": "The patient had bilateral optic neuritis.", "support_label": "not_supported", "original_label": "not_supported", "reasoning_audit": "No explicit tags provided.", "is_refined": true }, { "subclaim": "The optic neuritis had been persistently worsening for 2 years.", "support_label": "not_supported", "original_label": "not_supported", "reasoning_audit": "No explicit tags provided.", "is_refined": true }, { "subclaim": "Demyelinating plaques were identified within the corpus callosum on magnetic resonance imaging.", "support_label": "supported", "is_refined": false }, { "subclaim": "The initial work-up led to a diagnosis of multiple sclerosis.", "support_label": "supported", "is_refined": false }, { "subclaim": "Three months after the MS diagnosis, the patient presented with obstructive hydrocephalus.", "support_label": "supported", "is_refined": false }, { "subclaim": "The obstructive hydrocephalus was due to a newly diagnosed intraventricular mass.", "support_label": "supported", "is_refined": false }, { "subclaim": "The patient underwent an endoscopic third ventriculostomy.", "support_label": "supported", "is_refined": false }, { "subclaim": "A biopsy was performed.", "support_label": "supported", "is_refined": false }, { "subclaim": "The biopsy confirmed the diagnosis of CNS germinoma.", "support_label": "supported", "is_refined": false } ] }, { "id": "multiclinsum_test_626_en.txt", "fulltext": "In December 2013, a 58-year-old man with a history of type-2 diabetes mellitus (DM2), systemic arterial hypertension (SAH) and dyslipidemia was referred to our centre, the Hospital de Clínicas de Sao Paulo, a large academic and public centre located in Sao Paulo, Brazil, from the primary care service to investigate uncontrolled blood pressure and blood glucose. At initial clinical examination, he presented facial phletora, hirsutism, violaceous striae and centripetal obesity, and a CS clinical diagnosis was suspected. Initial examinations identified hypercortisolism and elevation of ACTH . The ACTH increment in the corticotropin-releasing hormone (CRH) stimulation test was 14%, suggesting an ectopic ACTH-producing tumour. To confirm this hypothesis, the patient underwent an inferior petrosal sinus sampling with CRH stimulation. The central/peripheral ACTH gradient was less than 2 at 0, 3, 5 and 10 min after desmopressin injection, confirming the ectopic ACTH producing. Magnetic resonance image (MRI) of the abdomen showed an expansive lesion in the tail of the pancreas measuring 5.0 cm in the largest diameter, multiple small nodules in hepatic segment III and increased volume of both adrenals . In January 2014, he was referred to our institution, the Instituto do Cancer do Estado de Sao Paulo, where he underwent an R0 body-caudal pancreatectomy, splenectomy and removal of the segment III of the liver, which was compatible with PNET, infiltrating the liver tissue. The final diagnosis was of a well-differentiated PNET, with positive immunohistochemistry staining of synaptophysin and chromogranin A, three mitosis/10 high-power fields and Ki67 index of 6%. There was adequate clinical control of DM2 and SAH after resection. In July 2014, a Gallium-68-DOTATATE PET-CT was performed and did not show any measurable metastatic disease. However, in November 2014, he presented hyperglycaemia and high blood pressure again, associated with elevation of both serum cortisol and ACTH, which were resultant from hepatic recurrence with a new lesion of 1.2 cm in segment VI of the liver. Because the patient was quite sick to undergo new hepatic resection due to uncontrolled CS and also because of the short interval from last metastasectomy, new surgical resection was contraindicated. Octreotide LAR 20 mg IM once every 28 days was started but was unsuccessful in controlling symptoms. Subsequent hepatic embolisation did not improve his condition either. Due to uncontrolled CS in February 2015, bilateral adrenalectomy was performed and the CS finally resolved. The pathology report revealed a metastatic neuroendocrine tumour in the left adrenal, with immunohistochemistry staining positive for synaptophysin, chromogranin A positive and ACTH, negative staining for CD56, CDX2 and TTF1 negative and ki67 index of 30%.\nAfter symptom control, the patient was lost to follow up, returning six months with recurrent hyperglycaemia and skin hyperpigmentation; at that time, the elevation of plasma ACTH was identified. A new MRI of the abdomen showed a progression of hepatic metastases. Octreotide LAR was tried again, but there was disease progression after two doses. In October 2015, he received the combination of oxaliplatin 130 mg/m2 given on day one and capecitabine 1000 mg/m2 (CapOx) orally for 14 days, in a 21-days cycle. At this time, he presented diffuse exuberant hyperpigmented lesions of the skin, mainly in interphalangeal joints and tongue . After two cycles, there was significant improvement in cutaneous hyperpigmentation and the patient was restaged with new CT scans that showed stable disease. Despite good tolerance, the patient requested to stop chemotherapy and he went on chemoholiday. In March 2016, after three months without treatment, the hyperpigmented lesions of the skin worsened and imaging tests evidenced new progression of liver disease. Re-exposure to CapOx was indicated. He received three more cycles, when in in April/2016, CT scans demonstrated partial response in liver lesions. The patient chose to pause the chemotherapy once again. At the last image evaluation, in June 2017, the tumour has remained stabilised and three has been no further worsening of skin hyperpigmentation.", "summary": "A 58-year-old man with a history of type-2 diabetes mellitus and arterial hypertension was diagnosed with Cushing's syndrome (CS) secondary to an ACTH ectopic production from a well-differentiated neuroendocrine tumour of the pancreas metastatic to the liver. The patient underwent initial body-caudal pancreatectomy, splenectomy and hepatic nodulectomy with subsequent recurrence. Hepatic embolisation and somatostatin analogues were used to control CS but without success. Bilateral adrenalectomy led to CS control, while capecitabine and oxaliplatin (CAPOX) was effective in controlling tumour growth and ACTH production.", "subclaim_evaluations": [ { "subclaim": "The patient is a 58-year-old man.", "support_label": "supported", "is_refined": false }, { "subclaim": "The patient has a history of type-2 diabetes mellitus.", "support_label": "supported", "is_refined": false }, { "subclaim": "The patient has a history of arterial hypertension.", "support_label": "supported", "is_refined": false }, { "subclaim": "The patient was diagnosed with Cushing's syndrome.", "support_label": "supported", "is_refined": false }, { "subclaim": "The Cushing's syndrome was secondary to an ACTH ectopic production.", "support_label": "supported", "is_refined": false }, { "subclaim": "The ACTH ectopic production was from a well-differentiated neuroendocrine tumour of the pancreas.", "support_label": "supported", "is_refined": false }, { "subclaim": "The tumour was metastatic to the liver.", "support_label": "supported", "is_refined": false }, { "subclaim": "The patient underwent body-caudal pancreatectomy.", "support_label": "supported", "is_refined": false }, { "subclaim": "The patient underwent splenectomy.", "support_label": "supported", "is_refined": false }, { "subclaim": "The patient underwent hepatic nodulectomy.", "support_label": "not_supported", "original_label": "not_supported", "reasoning_audit": "No explicit tags provided.", "is_refined": true }, { "subclaim": "The tumour recurred after surgery.", "support_label": "supported", "is_refined": false }, { "subclaim": "Hepatic embolisation was used to control Cushing's syndrome.", "support_label": "not_supported", "original_label": "not_supported", "reasoning_audit": "No explicit tags provided.", "is_refined": true }, { "subclaim": "Somatostatin analogues were used to control Cushing's syndrome.", "support_label": "supported", "is_refined": false }, { "subclaim": "Hepatic embolisation and somatostatin analogues were without success.", "support_label": "supported", "is_refined": false }, { "subclaim": "Bilateral adrenalectomy led to Cushing's syndrome control.", "support_label": "supported", "is_refined": false }, { "subclaim": "Capecitabine and oxaliplatin (CAPOX) was effective in controlling tumour growth.", "support_label": "supported", "is_refined": false }, { "subclaim": "Capecitabine and oxaliplatin (CAPOX) was effective in controlling ACTH production.", "support_label": "not_supported", "original_label": "not_supported", "reasoning_audit": "No explicit tags provided.", "is_refined": true } ] }, { "id": "multiclinsum_test_2501_en.txt", "fulltext": "A 76-year-old woman presented at our department with an abdominal pulsatile mass. She had hypertension (nifedipine 20 mg, candesartan 4 mg, indapamide 0.5 mg), dyslipidemia, congestive heart failure, and complete atrioventricular block. She had previously undergone an operation that included endovascular aneurysm repair and prophylactic accessory renal artery coil embolization for advanced uterine cancer. Enhanced computed tomography (CT) imaging revealed an abdominal aortic aneurysm (AAA) with a maximum diameter of 53 × 57 mm and a right ARA (4 mm in diameter) . Since open repair was considered risky due to her coexisting diseases, we decided to perform EVAR despite the presence of ARA.\nUnder general anesthesia, bilateral transfemoral access was obtained via surgical cutdown, and 7Fr short sheaths were placed in both common femoral arteries. Prior to EVAR, the ARA was selectively catheterized with a 6Fr RDC guiding catheter and a 5Fr RDC catheter, and embolization was performed with two 0.018-in coils (Interlock, Boston Scientific, Marlborough, MA, USA). After coiling, the main body of the stentgraft (Aorfix™, Lombard Medical, Oxfordshire, UK) was deployed with its proximal end just below the renal arteries, and bilateral common iliac arteries were used as distal landing zones. We completed the procedures having seen no perfusion defect of the inferior pole of the right kidney from the right renal artery on completion angiography .\nThe postoperative course was uneventful, and the patient was discharged 7 days later. Postoperative eGFR (58.4 ml/min) was not significantly different from preoperative (56.7 ml/min). After surgery, blood pressure was under control, and no additional blood pressure medicines were required. Postoperative enhanced CT showed that there was no endoleak. The distal portion of her right ARA from coils including the right kidney was well perfused .", "summary": "A 76-year-old woman was admitted to our hospital after noticing an abdominal pulsatile mass. Computed tomography (CT) imaging revealed an abdominal aortic aneurysm (AAA) with a maximum diameter of 53 mm. Preoperative CT scan showed a right ARA, 4 mm in diameter, which was considered likely to lead to type II endoleak following EVAR. ARA coil embolization was performed at the time of EVAR. We observed no endoleaks and no infarct of the inferior pole of the right kidney on completion angiography. The postoperative course was uneventful, and the patient was discharged 7 days later. Postoperative eGFR (58.4 ml/min) was not significantly different from preoperative level (56.7 ml/min). After EVAR, blood pressure was under control, and no additional anti-hypertensive medicines were required. Postoperative enhanced CT image showed that the distal portion of the ARA was well perfused without type II endoleak from ARA.", "subclaim_evaluations": [ { "subclaim": "The patient was a 76-year-old woman.", "support_label": "supported", "is_refined": false }, { "subclaim": "She was admitted after noticing an abdominal pulsatile mass.", "support_label": "supported", "is_refined": false }, { "subclaim": "Computed tomography imaging revealed an abdominal aortic aneurysm.", "support_label": "supported", "is_refined": false }, { "subclaim": "The maximum diameter of the aneurysm was 53 mm.", "support_label": "supported", "is_refined": false }, { "subclaim": "A right accessory renal artery was identified on preoperative CT.", "support_label": "supported", "is_refined": false }, { "subclaim": "The right accessory renal artery was 4 mm in diameter.", "support_label": "supported", "is_refined": false }, { "subclaim": "The right accessory renal artery was considered likely to lead to type II endoleak following EVAR.", "support_label": "supported", "is_refined": false }, { "subclaim": "The patient underwent EVAR.", "support_label": "supported", "is_refined": false }, { "subclaim": "ARA coil embolization was performed at the time of EVAR.", "support_label": "supported", "is_refined": false }, { "subclaim": "No endoleaks were observed on completion angiography.", "support_label": "supported", "is_refined": false }, { "subclaim": "No infarct of the inferior pole of the right kidney was observed on completion angiography.", "support_label": "supported", "is_refined": false }, { "subclaim": "The postoperative course was uneventful.", "support_label": "supported", "is_refined": false }, { "subclaim": "The patient was discharged 7 days after the procedure.", "support_label": "supported", "is_refined": false }, { "subclaim": "Postoperative eGFR was 58.4 ml/min.", "support_label": "supported", "is_refined": false }, { "subclaim": "Preoperative eGFR was 56.7 ml/min.", "support_label": "supported", "is_refined": false }, { "subclaim": "Postoperative eGFR was not significantly different from preoperative eGFR.", "support_label": "supported", "is_refined": false }, { "subclaim": "Blood pressure was under control after EVAR.", "support_label": "supported", "is_refined": false }, { "subclaim": "No additional anti-hypertensive medicines were required after EVAR.", "support_label": "supported", "is_refined": false }, { "subclaim": "Postoperative enhanced CT showed the distal portion of the ARA was well perfused.", "support_label": "supported", "is_refined": false }, { "subclaim": "Postoperative enhanced CT showed no type II endoleak from the ARA.", "support_label": "supported", "is_refined": false } ] }, { "id": "multiclinsum_test_697_en.txt", "fulltext": "Our patient was a 43-year-old man with a weight of 93 kg and height of 174 cm. He had been undergoing hemodialysis for 20 years because of chronic renal failure. He had been taking cinacalcet, calcium carbonate, montelukast, loratadine, and nalfurafine before the surgery. There were no preoperative symptoms of suspected pheochromocytoma and no history of hypertension. His blood pressure was 140/82 mmHg, heart rate 76 beats/min, body temperature 36.2 °C, and normal respiratory rhythm with an O2 saturation of 96% on room air. Blood tests demonstrated BUN of 60.2 mg/dL and creatinine of 13.3 mg/dL, but coagulability, liver function, and electrolytes were normal.\nA close examination of hematuria revealed a tumor in the right renal pelvis, and retroperitoneal total right nephroureterectomy was scheduled. The tumor in the right adrenal gland was followed up because there was no clear malignant finding on CT. On the day before surgery, 5100 mL of body fluid was removed by hemodialysis. Propofol and remifentanil were used for the induction and maintenance of anesthesia. After tracheal intubation, periodic systolic blood pressure fluctuations within the range of 70–260 mmHg, diastolic blood pressure fluctuations within the range of 40–90 mmHg, and heart rate of 80–110 beats/min were observed at intervals of approximately 8 min . Intermittent and continuous administration of nicardipine was not effective for suppressing the fluctuation, which lasted for approximately 3 h and disappeared spontaneously after completion of laparoscopic surgery. Intermittent and continuous administration of nicardipine was performed because of this circulatory fluctuation; however, it could not be suppressed. Periodic blood pressure fluctuations disappeared spontaneously at the end of laparoscopic surgery. Blood samples were collected during the cycle of circulatory fluctuations. The catecholamine levels of the blood samples were as follows: first blood pressure fluctuation: adrenaline 3.22 ng/mL, noradrenaline 1.98 ng/mL, and dopamine 0.02 ng/mL; second blood pressure fluctuation: adrenaline 6.32 ng/mL, noradrenaline 3.12 ng/mL, and dopamine 0.02 ng/mL; and at the end of blood pressure fluctuation: adrenaline 0.36 ng/mL, noradrenaline 0.47 ng/mL, and dopamine 0.02 ng/mL. A postoperative examination revealed that the highest blood catecholamine levels were adrenaline, with 0.03 ng/mL (normal value: 0–0.10 ng/mL); noradrenaline, with 0.52 ng/mL (normal value: 0.10–0.50 ng/mL); and dopamine, with 0.03 ng/mL (normal value: 0–0.03 ng/ml). In addition, scintigraphy identified an increased uptake of 131iodine-metaiodobenzylguanidine corresponding to the left adrenal gland, suggesting pheochromocytoma . After the diagnosis of pheochromocytoma, oral treatment with doxazosin 2 mg/day was administered, and left adrenalectomy was performed 4 months after the initial surgery.\nBefore surgery, his blood pressure was 170/92 mmHg, heart rate 80 beats/min, body temperature 36.5 °C, and normal respiratory rhythm with an O2 saturation of 96% on room air. Blood tests demonstrated Hb of 10.4 g/dL, BUN of 46.9 mg/dL, and creatinine of 11.6 mg/dL, but coagulability, liver function, and electrolytes were normal. Echocardiography showed left ventricular hypertrophy and mild left ventricular wall hypokinesis. On the day before surgery, 4300 mL of body fluid was removed by hemodialysis. Pheochromocytoma resection was performed under general anesthesia with propofol and remifentanil. As with the initial surgery, periodic circulation fluctuations occurred after tracheal intubation at the time of anesthesia induction, but the fluctuations were approximately 10 min apart, and the degree of fluctuation was smaller than that of the first surgery. Intermittent and continuous administration of nicardipine and landiolol was performed for circulatory fluctuation; however, once again, the fluctuations could not be suppressed. Dopamine was administered to maintain circulation after tumor removal. The periodic fluctuations disappeared after the ligation of the left adrenal artery and did not occur thereafter. The intraoperative course of the second surgery is shown in Fig. .", "summary": "A 43-year-old man presented with periodic blood pressure fluctuations during surgery for a renal pelvic tumor. His blood levels of catecholamines (ng/mL) changed dramatically over a short time during blood pressure fluctuations: adrenaline 0.36 to 3.22, noradrenaline 0.47 to 1.98, and dopamine 0.02. After the diagnosis of pheochromocytoma, oral treatment with doxazosin 2 mg/day was administered, and left adrenalectomy was performed 4 months after the initial surgery. Periodic circulation fluctuations occurred after tracheal intubation at the time of anesthesia induction, but the degree of fluctuation was smaller than that of the first surgery.", "subclaim_evaluations": [ { "subclaim": "The patient is a 43-year-old man.", "support_label": "supported", "is_refined": false }, { "subclaim": "He had surgery for a renal pelvic tumor.", "support_label": "supported", "is_refined": false }, { "subclaim": "He had periodic blood pressure fluctuations during surgery.", "support_label": "supported", "is_refined": false }, { "subclaim": "His blood levels of catecholamines changed dramatically during blood pressure fluctuations.", "support_label": "supported", "is_refined": false }, { "subclaim": "Adrenaline levels ranged from 0.36 to 3.22 ng/mL.", "support_label": "supported", "is_refined": false }, { "subclaim": "Noradrenaline levels ranged from 0.47 to 1.98 ng/mL.", "support_label": "supported", "is_refined": false }, { "subclaim": "Dopamine levels were 0.02 ng/mL.", "support_label": "supported", "is_refined": false }, { "subclaim": "The diagnosis was pheochromocytoma.", "support_label": "supported", "is_refined": false }, { "subclaim": "Oral doxazosin 2 mg/day was administered.", "support_label": "supported", "is_refined": false }, { "subclaim": "Left adrenalectomy was performed 4 months after the initial surgery.", "support_label": "supported", "is_refined": false }, { "subclaim": "Periodic circulation fluctuations occurred after tracheal intubation at the time of anesthesia induction.", "support_label": "supported", "is_refined": false }, { "subclaim": "The degree of fluctuation was smaller than that of the first surgery.", "support_label": "supported", "is_refined": false } ] }, { "id": "multiclinsum_test_73_en.txt", "fulltext": "A 48-year-old man was admitted to Jinhua People's Hospital on June 29, 2021 due to change in stool habit for 5 d.\nHis symptoms started 5 d previously and were accompanied by a change in stool habit (yellow, thin, pasty stools 3-5 times a day, without mucus and blood). No significant change in body weight was noted.\nThe patient had a history of surgery for hypofractionated adenocarcinoma of the stomach 6 mo ago. According to the World Health Organization (WHO) Classification of Digestive System Tumor, hypofractionated adenocarcinoma is defined as the cancer cells are short columnar or indefinite, arranged in small nests or strands, and basically without glandular tube structure.\nThe patient had no relevant personal and family history.\nOn examination, his abdomen was soft, old surgical scars were visible in the upper abdomen, and no pressure pain, rebound pain, or masses were found.\nLaboratory examinationsshowed that routine blood, urine, stool, liver and kidney function, carcinoembryonic antigen, alpha-fetoprotein and carbohydrate antigen 199 were all within the normal range.\nThe patient was advised to undergo abdominal enhanced computed tomography (CT) and colonoscopy, and the results of colonoscopy on July 1, 2021 suggested a submucosal bulge approximately 1.0 cm × 1.0 cm in the rectum 8 cm from the anal verge, with red surface erosion . Narrow band imaging (NBI) and magnification colonoscopy showed uneven caliber and distribution of blood vessels. Type2B was considered according to JNET staging .", "summary": "We describe a case of rectal adenoma with submucosal pseudoinvasion in a 48-year-old man. The patient was admitted to Jinhua People's Hospital due to a change in stool habit for 5 d. We performed colonoscopy, and the results suggested a submucosal bulge approximately 1.0 cm × 1.0 cm in size in the rectum 8 cm from the anal verge, with red surface erosion. Ultrasound colonoscopy was also performed and a homogeneous hypoechoic mass about 0.52 cm × 0.72 cm in size was seen at the lesion, protruding into the lumen with clear borders and invading the submucosa. Endoscopic surgery was then performed and the pathological specimen showed a tubular adenoma with high-grade intraepithelial neoplasia (intramucosal carcinoma) involving the adenolymphatic complex. In addition, we performed a literature review of rectal tubular adenoma with submucosal pseudoinvasion to obtain a deeper understanding of this disease.", "subclaim_evaluations": [ { "subclaim": "The patient was a 48-year-old man.", "support_label": "supported", "is_refined": false }, { "subclaim": "The patient had a change in stool habit for 5 days.", "support_label": "supported", "is_refined": false }, { "subclaim": "Colonoscopy was performed.", "support_label": "supported", "is_refined": false }, { "subclaim": "A submucosal bulge approximately 1.0 cm × 1.0 cm in size was found in the rectum.", "support_label": "supported", "is_refined": false }, { "subclaim": "The submucosal bulge was 8 cm from the anal verge.", "support_label": "supported", "is_refined": false }, { "subclaim": "The lesion had red surface erosion.", "support_label": "supported", "is_refined": false }, { "subclaim": "Ultrasound colonoscopy showed a homogeneous hypoechoic mass about 0.52 cm × 0.72 cm in size.", "support_label": "not_supported", "original_label": "not_supported", "reasoning_audit": "No explicit tags provided.", "is_refined": true }, { "subclaim": "The mass protruded into the lumen.", "support_label": "supported", "is_refined": false }, { "subclaim": "The mass had clear borders.", "support_label": "supported", "is_refined": false }, { "subclaim": "The mass invaded the submucosa.", "support_label": "supported", "is_refined": false }, { "subclaim": "Endoscopic surgery was performed.", "support_label": "not_supported", "original_label": "not_supported", "reasoning_audit": "No explicit tags provided.", "is_refined": true }, { "subclaim": "The pathological specimen showed a tubular adenoma.", "support_label": "not_supported", "original_label": "not_supported", "reasoning_audit": "No explicit tags provided.", "is_refined": true }, { "subclaim": "The tubular adenoma had high-grade intraepithelial neoplasia.", "support_label": "not_supported", "original_label": "not_supported", "reasoning_audit": "No explicit tags provided.", "is_refined": true }, { "subclaim": "The high-grade intraepithelial neoplasia was classified as intramucosal carcinoma.", "support_label": "not_supported", "original_label": "not_supported", "reasoning_audit": "No explicit tags provided.", "is_refined": true }, { "subclaim": "The intramucosal carcinoma involved the adenolymphatic complex.", "support_label": "not_supported", "original_label": "not_supported", "reasoning_audit": "No explicit tags provided.", "is_refined": true }, { "subclaim": "A literature review of rectal tubular adenoma with submucosal pseudoinvasion was performed.", "support_label": "not_supported", "original_label": "not_supported", "reasoning_audit": "No explicit tags provided.", "is_refined": true } ] }, { "id": "multiclinsum_test_322_en.txt", "fulltext": "A 50 year-old Caucasian American man with history of chronic obstructive pulmonary disease was admitted for loss of consciousness. He was found on the floor by his son, who brought him to the emergency department. The son denied noticing any tongue bite or bowel or bladder incontinence. The patient was unresponsive on arrival to the emergency department.\nThe patient's home medications included albuterol inhaler as needed. He was smoking two packs of cigarettes daily, but the son denied history of alcohol or illicit drug intake. His vitals on presentation were: BP - 90/50 mmHg, HR - 116/min, RR - 28/min and Temp - 98.8°F, and he was saturating 92 percent on 2L oxygen via nasal cannula.\nHis physical examination was significant for unresponsiveness, crackles in his left lung base and scattered wheezes throughout the lungs. His lab work showed a high WBC of 26,400/L, with 72.5% neutrophils and 13.5% bands, potassium of 5.3 mEq/L, BUN of 15 mg/dL and creatinine of 1.9 mg/dL (his baseline creatinine was 1.1 mg/dL). Urine toxicology screen was positive for opioid. Other labs included elevated creatine kinase of 15,860 U/L and elevated myoglobin of 46,651 ng/ml. Urine was positive for pneumococcal antigen. CT scan of the head without contrast was normal. Chest x-ray showed an infiltrate in the left mid lung field.\nThe patient was admitted with a diagnosis of chronic obstructive pulmonary disease exacerbation secondary to pneumonia, fall with loss of consciousness secondary to severe sepsis, opioid abuse and acute renal failure secondary to rhabdomyolysis. He was started on intravenous steroids, antibiotics and bronchodilators. He was given intravenous fluid for his rhabdomyolysis and hypotension. Despite aggressive treatment of rhabdomyolysis his creatine kinase increased from 15,000 U/L on the day of admission to 45,000 U/L on day two and 80,000 U/L on day three. His serum creatinine level increased from 1.9 mg/dL on admission to 2.3 mg/dL on day two and 2.6 mg/dL on day three.\nOn day three, the patient became slightly responsive and started complaining of pain in his right hip. On inspection, the patient's right hip was swollen, and it was very firm and tender on palpation .\nCT scan of pelvis was done which demonstrated fullness of the right gluteal muscles secondary to edema or inflammation or compartment syndrome .\nAn MRI of the pelvis was recommended for further evaluation which showed enlargement of right gluteus minimus and medius muscles secondary to edema or hemorrhage with compartment syndrome . Gluteal compartment pressure was not checked as there seemed to be enough evidence from physical examination and rising serum creatinine and creatine kinase levels, that the patient's worsening rhabdomyolysis was secondary to the gluteal compartment syndrome.\nThe patient was taken to the operating room where he underwent multiple fasciotomies. A large area of clot was noted between gluteus maximus and medius which was evacuated and the area was irrigated. The patient's creatine kinase and serum creatinine level improved to normal on discharge to home, five days after the surgical procedure. On follow-up visit to the office, two weeks after the patient's discharge, he was doing fine with normalization of his renal function and absence of gait abnormality, sensory dysfunction or muscle weakness.", "summary": "A 50-year-old Caucasian American man with history of chronic obstructive pulmonary disease was admitted status post fall and loss of consciousness for an unknown duration. Initial work-up revealed severe rhabdomyolysis, opioid abuse and acute renal failure. Inspite of three days of intensive therapy his condition did not improve and his renal failure worsened. On improvement of his condition three days later, he indicated some discomfort in his right hip. Physical examination was significant for swelling of the right gluteal region, which was tender and firm on palpation. A non-contrast CT scan showed evidence of gluteal compartment syndrome and emergent surgery resulted in significant improvement of his condition.", "subclaim_evaluations": [ { "subclaim": "The patient is a 50-year-old man.", "support_label": "supported", "is_refined": false }, { "subclaim": "The patient is Caucasian American.", "support_label": "supported", "is_refined": false }, { "subclaim": "The patient has a history of chronic obstructive pulmonary disease.", "support_label": "supported", "is_refined": false }, { "subclaim": "The patient was admitted after a fall.", "support_label": "supported", "is_refined": false }, { "subclaim": "The patient had a loss of consciousness of unknown duration.", "support_label": "supported", "is_refined": false }, { "subclaim": "Initial work-up revealed severe rhabdomyolysis.", "support_label": "supported", "is_refined": false }, { "subclaim": "Initial work-up revealed opioid abuse.", "support_label": "supported", "is_refined": false }, { "subclaim": "Initial work-up revealed acute renal failure.", "support_label": "supported", "is_refined": false }, { "subclaim": "After three days of intensive therapy, his condition did not improve.", "support_label": "supported", "original_label": "not_supported", "reasoning_audit": "No explicit tags provided.", "is_refined": true }, { "subclaim": "His renal failure worsened.", "support_label": "supported", "is_refined": false }, { "subclaim": "On improvement of his condition three days later, he indicated some discomfort in his right hip.", "support_label": "supported", "is_refined": false }, { "subclaim": "Physical examination showed swelling of the right gluteal region.", "support_label": "supported", "is_refined": false }, { "subclaim": "The right gluteal region was tender on palpation.", "support_label": "supported", "is_refined": false }, { "subclaim": "The right gluteal region was firm on palpation.", "support_label": "supported", "is_refined": false }, { "subclaim": "A non-contrast CT scan showed evidence of gluteal compartment syndrome.", "support_label": "not_supported", "original_label": "not_supported", "reasoning_audit": "No explicit tags provided.", "is_refined": true }, { "subclaim": "Emergent surgery resulted in significant improvement of his condition.", "support_label": "supported", "is_refined": false } ] }, { "id": "multiclinsum_test_606_en.txt", "fulltext": "A 56-year-old man presented to our department with headache, vomiting, and gait disturbance (for 1 month). He had a past medical history of hepatitis type B virus infection and hepatic failure. He had been medically treated for hypertension and hepatitis for the previous 4 years. On admission, he had an impaired consciousness [Glasgow coma scale (GCS), 14]. Cerebellar ataxia and gait disturbance were evident. Diffusion weighted imaging (DWI) demonstrated multiple cerebellar infarctions at several intensities with perilesional edema of the left cerebellar hemisphere . Brain magnetic resonance imaging (MRI) did not reveal any prominent meningeal gadolinium enhancement or nodule . MR angiography revealed no abnormal findings. The main venous sinuses were confirmed to be patent by 3-dimensional reconstructions of MRI with gadolinium . Chest X-ray did not reveal any abnormal lesions, and the results of serum examination for infectious diseases, including human immunodeficiency virus (HIV), were negative except for hepatitis B virus surface antigen.\nSubsequently, the patient was diagnosed with subacute cerebellar infarction due to arteriosclerosis and was administered glycerol to control the intracranial pressure; however, 1 week after admission, his GCS decreased to 11. Computed tomography confirmed worsened cerebellar edema and hydrocephalus. External and internal decompression surgery were performed to control the intracranial pressure . A section of the swollen cerebellar hemisphere was removed and submitted as a surgical specimen. Additionally, external continuous ventricular drainage was performed to control hydrocephalus. Lumbar puncture to collect cerebral spinal fluid (CSF) was not performed until this time because of the risk of cerebral herniation. CSF from continuous ventricular drainage demonstrated mild inflammation (cell count, 36 /mm3; protein, 16 mg/dl; glucose, 113 mg/dl). C. neoformans was detected in CSF as well as in the surgical specimen of the cerebellum.\nHistopathologic examination of the surgical specimen revealed strong hyperplasia of the arachnoid mater . Fungi were mainly localized in the subarachnoid space and rarely in the parenchyma . Lymphocytes and multinucleated giant cells forming granulomata invaded the arachnoid and subarachnoid spaces and pia with heavy fibrosis . Small arteries were occasionally observed to be occluded with internal endothelial proliferation. While there were arteries in the sample, veins were rarely observed in the subarachnoid space . In addition, venules in the parenchyma were frequently observed to be congested. The patient was diagnosed with granulomatous meningitis due to C. neoformans and was immediately treated using liposomal amphotericin B and fluconazole; however, the ischemic lesion of the cerebellum continued to bilaterally worsen along with worsening perilesional edema . The patient’s course subsequently deteriorated. He developed renal failure and ultimately died 25 days after admission.\nAutopsy confirmed that the pathological changes were confined to the central nervous system and predominantly localized at the surface of the cerebellar hemisphere. Fungal bodies were widely spread along the surface and bilaterally into the deep sulcus of the cerebellum . Few fungi were observed in the supratentorial and intraparenchymal lesions. The lesion in the arachnoid mater of the cerebellum was roughly the same as that in the surgical specimen although it was more deeply spread into the peripheral sulcus and the granulomatous inflammation was not as severe .", "summary": "A 56-year-old man who suffered from dizziness and gait disturbance for one month was admitted to our hospital and subsequently diagnosed with a cerebellar infarction. He had a past medical history of hepatitis type B virus infection and hepatic failure. Although the findings on magnetic resonance imaging (MRI) imitated an arterial infarction of the posterior inferior cerebellar artery, an accompanying irregular peripheral edema was observed. The ischemic lesion progressed, subsequently exerting a mass effect and leading to impaired consciousness. External and internal decompression surgeries were performed. Cryptococcus neoformans was confirmed in the surgical specimen, and the patient was diagnosed with CM. In addition, venule congestion in the parenchyma was observed with extensive fibrosis and compressed veins in the subarachnoid space. The patient died 26 days after admission. Autopsy revealed that pathological changes were localized in the cerebellum.", "subclaim_evaluations": [ { "subclaim": "The patient was a 56-year-old man.", "support_label": "supported", "is_refined": false }, { "subclaim": "He had dizziness and gait disturbance for one month.", "support_label": "supported", "is_refined": false }, { "subclaim": "He was admitted to the hospital.", "support_label": "supported", "is_refined": false }, { "subclaim": "He was diagnosed with a cerebellar infarction.", "support_label": "supported", "is_refined": false }, { "subclaim": "He had a past medical history of hepatitis type B virus infection.", "support_label": "supported", "is_refined": false }, { "subclaim": "He had a past medical history of hepatic failure.", "support_label": "supported", "is_refined": false }, { "subclaim": "MRI findings imitated an arterial infarction of the posterior inferior cerebellar artery.", "support_label": "supported", "is_refined": false }, { "subclaim": "An irregular peripheral edema was observed.", "support_label": "supported", "original_label": "not_supported", "reasoning_audit": "No explicit tags provided.", "is_refined": true }, { "subclaim": "The ischemic lesion progressed.", "support_label": "supported", "is_refined": false }, { "subclaim": "The lesion exerted a mass effect.", "support_label": "supported", "is_refined": false }, { "subclaim": "The mass effect led to impaired consciousness.", "support_label": "supported", "is_refined": false }, { "subclaim": "External and internal decompression surgeries were performed.", "support_label": "supported", "is_refined": false }, { "subclaim": "Cryptococcus neoformans was confirmed in the surgical specimen.", "support_label": "supported", "is_refined": false }, { "subclaim": "The patient was diagnosed with CM.", "support_label": "supported", "is_refined": false }, { "subclaim": "Venule congestion in the parenchyma was observed.", "support_label": "supported", "is_refined": false }, { "subclaim": "Extensive fibrosis was observed.", "support_label": "supported", "is_refined": false }, { "subclaim": "Compressed veins in the subarachnoid space were observed.", "support_label": "not_supported", "original_label": "not_supported", "reasoning_audit": "No explicit tags provided.", "is_refined": true }, { "subclaim": "The patient died 26 days after admission.", "support_label": "not_supported", "original_label": "not_supported", "reasoning_audit": "No explicit tags provided.", "is_refined": true }, { "subclaim": "Autopsy revealed that pathological changes were localized in the cerebellum.", "support_label": "supported", "is_refined": false } ] }, { "id": "multiclinsum_test_2071_en.txt", "fulltext": "A 51-year-old man inadvertently noticed a cervical mass that had been growing rapidly for 1 month. On May 26, 2020, the patient went to the outpatient department of Fudan University Shanghai Cancer Center. He had no dyspnea and was in good clinical condition with an Eastern Cooperative Oncology Group performance status score of 0. However, he complained of pain on touching the mass. Therefore, cervical ultrasound (US) and thyroid computed tomography (CT) were performed in May 2020. Imaging results showed calcified masses on both the lobes and isthmus of the thyroid, suggesting the possibility of thyroid carcinoma. The trachea was shifted to the right and invasion of the internal jugular vein and common carotid artery was observed . Additionally, thyroid CT revealed multiple enlarged cervical nodes at levels II, III, and IV on the left side, each measuring approximately 20 mm. Core needle biopsy (CNB) of the prevailing thyroid nodule confirmed the diagnosis of ATC . Our center performs either immunohistochemistry and/or next-generation sequencing (88-gene somatic mutation analysis panel) as a standard of care for molecular testing of the tumor. NGS revealed three mutations: NRAS c.182A > T (variant allele frequency [VAF] 4.0%), TP53 c.742C > T (VAF 4.9%), and TERT C228T (VAF 3.5%). It was showed in immunohistochemically stained slides that tumor cells were positive for AE1/AE3, CK19, PAX8, P53 (70%), Ki67 (80%), TTF-1, HBME-1 . The cells were negative for thyroglobulin, desmin, and p63. Physical examination revealed a hard nodule sized 2–3 cm in the thyroid region and the trachea was displaced to the right. Abdominal US, brain CT, and chest CT detected no additional metastases. The patient was diagnosed with ATC (cT4bN1bM0, IVB according to the American Joint Committee on Cancer [AJCC] Cancer Staging Manual, 8th Edition) and the tumor was considered unresectable.\nIn June 2020, the patient was recruited for a clinical trial that combined multiple-target kinase inhibitors and anti-PD-1 antibodies in patients with advanced thyroid cancer (NCT04521348). He was administered three cycles of famitinib (20 mg/qd) and camrelizumab (200 mg/q3w). The patient exhibited a good clinical status, but suffered from famitinib-induced grade 3 hypertension, which was controlled with nifedipine and valsartan. Famitinib was discontinued for 3 days during the second cycle.\nAfter three cycles of treatment, CT showed partial response (PR) of the lesion according to the Response Evaluation Criteria in Solid Tumors (version 1.1) . The invaded internal jugular and common carotid arteries were separated. A multidisciplinary team for head and neck cancer offered the patient two main therapeutic options: surgical intervention or medical therapy. After discussion with the patient and his family members, the patient consented to total thyroidectomy and radical neck dissection, followed by radiotherapy.\nTotal thyroidectomy with removal of lymph node group VI and left radical neck dissection (groups II, III, IV, and V) were performed in July 2020. Postoperative pathological examination identified a 35-mm (maximum diameter) lesion in the left thyroid lobe and some poorly differentiated tumor nests with degeneration. Necrosis, desmoplasia, calcification, chronic inflammatory infiltration, and foamy histiocyte aggregates were found in the surrounding areas. Cholesterol crystals were observed occasionally, which was consistent with the changes observed after treatment . A 12-mm (maximum diameter) lesion in the right thyroid lobe was diagnosed as papillary thyroid cancer. Necrosis, chronic inflammatory cell infiltration, foam cell aggregation, cholesterol crystals, and multinucleated giant cell reaction were observed in the anterior cervical mass, which was consistent with the changes after treatment. No definite residual carcinomas were observed. None of the 33 neck lymph nodes involved in neck dissection showed signs of metastatic carcinoma. Thus, the diagnosis of ATC was confirmed (ypT2N0M0, IVA according to AJCC Cancer Staging Manual, 8th Edition).\nPostoperative therapy included L-thyroxine (125 μg/d). Positron emission tomography CT showed no masses in the thyroid or neck lymph nodes and no distant metastasis. By August 2020, the patient had recovered well and received intensity-modulated radiation therapy (IMRT) with a dose of 60 Gy (in 30 fractions) to the thyroid bed and cervical nodal regions and 54 Gy to the mediastinal nodes . Following radiation therapy, camrelizumab (200 mg/q3w) was administered for maintenance for 11 cycles. CT was performed to assess the response to camrelizumab in January 2021 .\nSurveys of patient-reported outcomes were obtained approximately 24 months after the diagnosis. They showed a very good quality of life, including continuation of normal activities such as jogging.", "summary": "In our phase II study, patients having advanced/metastatic solid ATCs were treated with famitinib and camrelizumab, a combination therapy involving a multi-targeted kinase inhibitor and an anti-PD-1 antibody. We report a case of a patient with locally advanced unresectable ATC who underwent this combination therapy, allowing us to perform complete surgical resection followed by post-operative radiation therapy.", "subclaim_evaluations": [ { "subclaim": "The study was a phase II trial.", "support_label": "not_supported", "original_label": "not_supported", "reasoning_audit": "No explicit tags provided.", "is_refined": true }, { "subclaim": "The study involved patients with advanced/metastatic solid ATCs.", "support_label": "supported", "is_refined": false }, { "subclaim": "Patients were treated with famitinib.", "support_label": "supported", "is_refined": false }, { "subclaim": "Patients were treated with camrelizumab.", "support_label": "supported", "is_refined": false }, { "subclaim": "Famitinib is a multi-targeted kinase inhibitor.", "support_label": "supported", "is_refined": false }, { "subclaim": "Camrelizumab is an anti-PD-1 antibody.", "support_label": "supported", "is_refined": false }, { "subclaim": "The therapy combination included famitinib and camrelizumab.", "support_label": "supported", "is_refined": false }, { "subclaim": "A case of a patient with locally advanced unresectable ATC was reported.", "support_label": "supported", "is_refined": false }, { "subclaim": "The patient underwent combination therapy with famitinib and camrelizumab.", "support_label": "supported", "is_refined": false }, { "subclaim": "The patient had complete surgical resection.", "support_label": "supported", "is_refined": false }, { "subclaim": "The patient received post-operative radiation therapy.", "support_label": "supported", "is_refined": false } ] }, { "id": "multiclinsum_test_12_en.txt", "fulltext": "A 15-year-old boy presented to our University Hospital, a tertiary care neurology facility, with fever, headache, and altered sensorium of 12-day duration. At admission, he was febrile (101 °F), with a pulse rate of 110/min and a blood pressure recording of 114/74 mmHg; his Glasgow Coma Scale score was 10 (E3M4V3). There were no petechiae or signs of bleeding over the skin or any mucosal surface. There was no focal neurological deficit and neurological examination was normal, including (absence of) signs of meningeal irritation. Laboratory evaluation revealed the following estimations: hemoglobin of 11 g/dl, total leukocyte count of 3300 cells/mm3, and platelet count of 22,000 cells/mm3 which dropped to 8000 cells/mm3 on next day. His aspartate aminotransferase level was 155 U/L, alanine aminotransferase was 140 U/L and alkaline phosphatase was 56 U/L. Additional biochemical parameters, renal function tests, blood sugar, electrolytes, and arterial blood gas analysis, were normal. Malarial parasite was not detected in the peripheral blood smear. The cerebrospinal fluid examination, cytological and biochemical, was normal. IgM antibody against dengue virus was positive both in serum and cerebrospinal fluid; meanwhile, dengue NS1 antigen was negative. Electroencephalography revealed generalized slowing. On magnetic resonance imaging of the brain, signal changes were seen in bilateral parietooccipital and left frontal region (left hemisphere was more involved than the right hemisphere). There were diffuse subcortical white matter changes along with suggestion of hemorrhage on gradient echo sequence. Subtle hyperintensity on T2 W images was also noted in bilateral basal ganglia. Gadolinium-contrast study revealed a gyriform enhancement suggestive of cortical laminar necrosis . He was managed conservatively and given platelet transfusion. The patient responded well to management and became fully conscious in 7 days.", "summary": "A 15-year boy presented with fever, the headache and altered sensorium of 12-day duration. On neurological examination, his Glasgow Coma Scale score was 10 (E3M4V3). There was no focal neurological deficit. Laboratory evaluation revealed leukopenia and marked thrombocytopenia. Dengue virus IgM antibody was positive both in serum and cerebrospinal fluid. Magnetic resonance imaging of the brain revealed signal changes in bilateral parietooccipital and left frontal regions (left hemisphere more involved than the right hemisphere). There was gyriform enhancement bilateral parietooccipital regions consistent with cortical laminar necrosis. Bilaterally diffuse subcortical white matter was also involved and subtle T2 hyperintensity involving both basal ganglia was noted. Gradient echo sequence revealed presence of hemorrhage in the subcortical white matter. Patient was treated conservatively and received platelet transfusion. Patient became fully conscious after 7 days.", "subclaim_evaluations": [ { "subclaim": "The patient is a 15-year-old boy.", "support_label": "supported", "is_refined": false }, { "subclaim": "He had fever, headache, and altered sensorium for 12 days.", "support_label": "supported", "is_refined": false }, { "subclaim": "On neurological examination, his Glasgow Coma Scale score was 10.", "support_label": "supported", "is_refined": false }, { "subclaim": "There was no focal neurological deficit.", "support_label": "supported", "is_refined": false }, { "subclaim": "Laboratory evaluation showed leukopenia.", "support_label": "supported", "is_refined": false }, { "subclaim": "Laboratory evaluation showed marked thrombocytopenia.", "support_label": "supported", "is_refined": false }, { "subclaim": "Dengue virus IgM antibody was positive in serum.", "support_label": "supported", "is_refined": false }, { "subclaim": "Dengue virus IgM antibody was positive in cerebrospinal fluid.", "support_label": "supported", "is_refined": false }, { "subclaim": "MRI showed signal changes in bilateral parietooccipital and left frontal regions.", "support_label": "supported", "is_refined": false }, { "subclaim": "The left hemisphere was more involved than the right hemisphere.", "support_label": "supported", "is_refined": false }, { "subclaim": "There was gyriform enhancement in bilateral parietooccipital regions.", "support_label": "supported", "is_refined": false }, { "subclaim": "The enhancement was consistent with cortical laminar necrosis.", "support_label": "supported", "is_refined": false }, { "subclaim": "Bilaterally diffuse subcortical white matter was involved.", "support_label": "supported", "is_refined": false }, { "subclaim": "Subtle T2 hyperintensity was noted in both basal ganglia.", "support_label": "supported", "is_refined": false }, { "subclaim": "Gradient echo sequence showed hemorrhage in subcortical white matter.", "support_label": "supported", "is_refined": false }, { "subclaim": "The patient received platelet transfusion.", "support_label": "supported", "is_refined": false }, { "subclaim": "The patient became fully conscious after 7 days.", "support_label": "supported", "is_refined": false } ] }, { "id": "multiclinsum_test_959_en.txt", "fulltext": "We reported a case of a 46 years old woman admitted to our hospital because of prolonged recurrent vomiting in a severe state of malnutrition. A year before she had been submitted to duodenopancreatectomy because of a stenotic duodenal adenocarcinoma. Immediately, after hospital admission she underwent to a new explorative laparotomy because of worsening symptoms. In this second abdominal surgery she underwent to gastric enteric anastomosis because of sub-occlusion.\nHer ability to absorb substances was already compromised by the first operation. During the last year she did not received an adequate nutrition, moreover she had no vitamins supplement in her diet. After the second surgery she was fed by total parenteral nutrition with glucose solutions, amino-acids solutions and vitamins complex (Cernevit – Baxter@ spa, Roma, Italy) commonly administered to post-surgical patients containing 3,51 mg of thiamine.\nAfter five days from the gastric enteric anastomosis, she developed a Pseudomonas Aeruginosa’s severe sepsis with acute renal failure; so, she was transferred to our Intensive Care Unit (ICU). At ICU admission, she was agitated but she still had a normal Glasgow Coma Scale (GCS 15/15). Brain Computed Tomography (CT) scan control was negative and altered neurological status of the patient was imputed to the severe sepsis. Her blood tests showed leucopenia (1680/ml) and thrombocytopenia (34000/μl).\nWe performed an electroencephalogram (EEG) control that evidenced slow diffused anomalies, without paroxysms or focal signs. During the night she was sedated with benzodiazepines and intubated because of respiratory worsening.\nThe following day, at the neurological examination she was drowsy, she had no response to pain stimuli, no oculocephalic reflex, limbs areflexia and negative Babinski reflex. A new EEG control pointed out a diffused cerebral suffering state. Simultaneously her renal and liver function got worse due to the evolution of the septic state. Her feeding was still composed by glucose solutions, vitamins (Cernevit – Baxter@ spa, Roma, Italy) and amino acid intravenously administered. Then, we decided to perform a new brain CT scan with contrast in order to diagnose the cause of the worsening. This CT scan was performed at day 7 after surgery. The report of the CT scan showed a faded hyperdensity of the mammillary bodies and symmetrical hemorrhagic lesions in the quadrigeminal plate . The report suggested the need of a further diagnostic study with MRI because of the suspicion of a possible metabolic encephalopathy compatible with WE complicated by petechial hemorrhages.After the CT scan, we introduced thiamine 100 mg intravenously once a day, as supplement to the usual feeding. At the following neurological examination her GCS was 7/15, she did not open her eyes, did not emit verbal responses and localized with the right arm to painful stimuli. So 2 days later, we performed a brain magnetic resonance imaging (MRI). The MRI confirmed the lesions described in the CT scan and also added some elements compatible with WE: hyperintensity lesions in T-2 weighted images in the hypothalamus, medial thalamus, periaqueductal grey matter, anatomical regions of the mammillary bodies and superior cerebellar peduncles. , Mammillary bodies and optic tracts were difficult to assess due to a sub acute blood clot occupying the lower anterior portion of the third ventricle. The study was concluded with the MRI angiography to exclude a malformation of the vessels that had been able to generate the bleeding. Anyway, MRI angiography 3D-TOF was negative for vascular malformations. All these radiological findings were consistent with the diagnosis of WE. In the meantime, patients developed septic shock due to multi-resistant drug Enterococcus Faecium with severe low platelets count needing a mean of 20 Units of platelets transfused per day to maintain a serum level greater than 30000/μl.\nNo neurosurgical indications were given for the hemorrhagic brain lesions. So, we increased thiamine dosage up to 250 mg intravenously three times per day. This therapy was prolonged for one week, and after 4 days of high-dose thiamine supplementation neurological status of the patient had a significant improvement despite severe septic shock, she was able to open her eyes spontaneously and she performed simple commands.\nNevertheless, septic shock worsened and thrombocytopenia became refractory to platelets transfusions, hemodynamic instability became unresponsive to vasopressors and liver hypoperfusion worsened. Despite severe efforts used to control septic shock and thrombocytopenia, she died on the 21st day after surgery because of massive cerebral bleeding and unresponsive cerebral edema. The macroscopic autopsy of the brain was not nullifying because intracerebral hemorrhage and severe cerebral edema led to colliquation the typical areas of the Wernicke’s disease.", "summary": "We reported a case of a 46 years old woman who underwent, one year before, to cephalic duodenopancreatectomy complicated with prolonged recurrent vomiting. She underwent to a second surgical operation for intestinal sub-occlusion and postoperatively she developed septic shock and hemorrhagic Wernicke's disease. After ICU admission, because of neurological deterioration, she underwent CT scan and MRI that highlighted a strong suspicion for Wernicke's disease. We treated her with an initially wrong low dose of thiamine, then after MRI we increased the dosage with a neurological status improvement. Despite therapeutic efforts used to control septic shock and thrombocytopenia, she died on the 21st day after surgery because of massive cerebral bleeding and unresponsive cerebral edema.", "subclaim_evaluations": [ { "subclaim": "The patient was a 46-year-old woman.", "support_label": "supported", "is_refined": false }, { "subclaim": "She had undergone a cephalic duodenopancreatectomy one year before.", "support_label": "supported", "is_refined": false }, { "subclaim": "The cephalic duodenopancreatectomy was complicated by prolonged recurrent vomiting.", "support_label": "supported", "is_refined": false }, { "subclaim": "She underwent a second surgical operation for intestinal sub-occlusion.", "support_label": "supported", "is_refined": false }, { "subclaim": "After the second operation, she developed septic shock.", "support_label": "supported", "is_refined": false }, { "subclaim": "After the second operation, she developed hemorrhagic Wernicke's disease.", "support_label": "supported", "is_refined": false }, { "subclaim": "She was admitted to the ICU due to neurological deterioration.", "support_label": "supported", "is_refined": false }, { "subclaim": "A CT scan and MRI were performed.", "support_label": "supported", "is_refined": false }, { "subclaim": "The CT scan and MRI showed a strong suspicion for Wernicke's disease.", "support_label": "supported", "is_refined": false }, { "subclaim": "She was initially treated with a low dose of thiamine.", "support_label": "supported", "is_refined": false }, { "subclaim": "After the MRI, the thiamine dosage was increased.", "support_label": "supported", "is_refined": false }, { "subclaim": "Neurological status improved after increasing the thiamine dosage.", "support_label": "supported", "is_refined": false }, { "subclaim": "She died on the 21st day after surgery.", "support_label": "supported", "is_refined": false }, { "subclaim": "The cause of death was massive cerebral bleeding.", "support_label": "supported", "is_refined": false }, { "subclaim": "The cause of death was unresponsive cerebral edema.", "support_label": "supported", "is_refined": false } ] }, { "id": "multiclinsum_test_2123_en.txt", "fulltext": "A 76 year old ‘never smoker’ female with no past medical history was diagnosed with locally advanced NSCLC during investigations for a community-acquired lower respiratory tract infection. The Medical Research Council (MRC) Dyspnoea Score was 3 and there was a dry cough. Computed tomography (CT) of the chest demonstrated a 4.5 cm (anterior-posterior) × 4.1 cm (craniocaudal) left lung upper lobe mass with abutment of the mediastinal pleura and distal atelectasis and pneumonitis .\nAn 8 mm ipsilateral lymph node was visible at station 10. Multiple sub-centimetre lung nodules were noted throughout the right lung. Histological and immunohistochemical assessment of core biopsies from the primary lesion via bronchoscopy favoured the adenocarcinoma subtype of NSCLC (see Table ). The molecular analysis revealed ALK fusion protein overexpression along with ALK rearrangement. This result is in keeping with an ALK rearranged adenocarcinoma. The main lesion had an SUVmax of 16 on 18fluorodeoxyglucose positron emission topography-CT (PET-CT) imaging and no other lesions were avid. Following a review of the imaging at the multidisciplinary meeting (MDM), staging was offered at T2 N0 M0 (TNM 8 ), and in light of the patient’s fitness, radical treatment was recommended.\nDuring the assessment period for a primary lobectomy, the patient developed symptomatic atrial fibrillation. She underwent a successful direct current (DC) cardioversion and was discharged on edoxaban. Three weeks later the patient was noted to be in atrial fibrillation once more during an inpatient admission for the management of chest sepsis, for which she was discharged on digoxin. She was electively admitted to the Cardiology ward 6 weeks later for a second DC cardioversion procedure. Under conscious sedation, the patient received one synchronised shock of 120 J delivered via anterior-posterior paddles ie one placed at the left parasternal edge, one at the corresponding position on the patient’s back. One week post-procedure the patient attended the Emergency Department complaining of dysarthria and left-sided hemiparesis. CT and magnetic resonance imaging (MRI) of the brain confirmed the presence of a dense right-sided middle cerebral artery territory infarction (see Fig. ). The patient was in sinus rhythm, transthoracic echocardiography was unremarkable and mild bilateral carotid atheroma only was noted on ultrasonography (< 50% stenosis), suggestive for a stroke secondary to a delayed cardiogenic embolus related to atrial fibrillation, despite anticoagulation.\nFive days later, haemorrhagic transformation of the stoke was detected on MRI following clinical deterioration. A 3.5 cm intracerebral haematoma was identified within the right basal ganglia, causing effacement of the right lateral ventricle frontal horn, which was managed conservatively. The clinical condition stabilised and both her speech and weakness improved with rehabilitation from the department of Stroke Medicine.\nAs the patient’s ECOG PS recovered to 2 and her breathlessness resolved, work-up for radical treatment resumed, given her ongoing determination to gain control over the cancer. Updated cross-sectional imaging demonstrated complete regression of the left upper lobe lesion and a reduction of the previously documented mediastinal lymph node. Remaining atelectasis had a maximum standard uptake value (SUVmax) 2.7 on repeat PET-CT imaging (8 months since first PET). A review of the patient’s medications was undertaken searching for possible effects on FDG uptake, which was negative. The merits and risks of radical radiotherapy versus active surveillance were explored with the patient who elected to proceed with the latter.\nClinical review after 6 months of active surveillance, dry cough and mild dyspnoea were reported by the patient. Corresponding with the imaging findings, thoracic imaging with CT showed increased patchy parenchymal changes at the site of the previous left upper lobe lesion without associated hilar or mediastinal lymphadenopathy. Repeat PET-CT imaging demonstrated increased uptake (SUVmax 10.2) in a sub-pleural 4 cm mass in keeping with local relapse (see Fig. ), and no additional sites of disease.\nAs the pulmonary function tests (FEV1 90% predicted; TLCO 80% predicted) were favourable and physical fitness had stabilised (ECOG PS 2) the patient was consented for a course of radical thoracic radiotherapy without chemotherapy. She completed 55 Gy in 20 fractions planned with the intensity modulated radiotherapy technique and delivered as 6 MV arc therapy, with daily online cone beam-CT image guidance, treating Monday to Friday for 4 weeks . Target volumes were subject to peer review . Tumour shrinkage was noted during routine offline imaging review.\nThere were no acute toxicities during routine clinical assessments on treatment, or at 6 weeks post-radiotherapy. On clinical review 4 months after treatment completion the patient was more frail and had continued respiratory symptoms. Around this time, the first radiological follow-up scan demonstrated radiation pneumonitis focally in left upper lobe. At 1 year the patient returned to ECOG PS 1 and the imaging demonstrated stable disease locally and no evidence of distant relapse. At 18 months post-radiotherapy there was radiologic progression in the lungs with new pulmonary nodules and effusion and new bone metastases correlating with new symptoms of dyspnoea, cough and back pain. Owing to poor performance status, she was not considered fit for systemic therapy including ALK-targeted therapy and was managed with multi-disciplinary best supportive care until her death 5 months later.", "summary": "A 76 year old 'never smoker' female with an ALK-rearranged left upper lobe T2 N0 NSCLC experienced a stroke following elective DC cardioversion for new atrial fibrillation. Following a good recovery, updated imaging demonstrated complete regression of the left upper lobe lesion and a reduction of the previously documented mediastinal lymph node. Remaining atelectasis was non-avid on repeat PET-CT imaging, 8 months from the baseline PET-CT. When the patient developed new symptoms 6 months later a further PET-CT demonstrated FDG-avid local recurrence. She completed 55 Gy in 20 fractions but at 18 months post-radiotherapy there was radiological progression in the lungs with new pulmonary metastases and effusion and new bone metastases. Owing to poor performance status, she was not considered fit for targeted therapy and died 5 months later.", "subclaim_evaluations": [ { "subclaim": "The patient is a 76-year-old female.", "support_label": "supported", "is_refined": false }, { "subclaim": "The patient is a 'never smoker'.", "support_label": "supported", "is_refined": false }, { "subclaim": "The patient has an ALK-rearranged left upper lobe T2 N0 NSCLC.", "support_label": "supported", "is_refined": false }, { "subclaim": "The patient experienced a stroke.", "support_label": "supported", "is_refined": false }, { "subclaim": "The stroke occurred following elective DC cardioversion.", "support_label": "supported", "is_refined": false }, { "subclaim": "The cardioversion was for new atrial fibrillation.", "support_label": "supported", "is_refined": false }, { "subclaim": "Updated imaging demonstrated complete regression of the left upper lobe lesion.", "support_label": "supported", "is_refined": false }, { "subclaim": "The previously documented mediastinal lymph node was reduced.", "support_label": "supported", "is_refined": false }, { "subclaim": "Remaining atelectasis was non-avid on repeat PET-CT imaging.", "support_label": "supported", "is_refined": false }, { "subclaim": "The repeat PET-CT was 8 months from the baseline PET-CT.", "support_label": "supported", "is_refined": false }, { "subclaim": "The patient developed new symptoms 6 months later.", "support_label": "supported", "is_refined": false }, { "subclaim": "A further PET-CT demonstrated FDG-avid local recurrence.", "support_label": "supported", "is_refined": false }, { "subclaim": "The patient completed 55 Gy in 20 fractions.", "support_label": "supported", "is_refined": false }, { "subclaim": "At 18 months post-radiotherapy, there was radiological progression in the lungs.", "support_label": "supported", "is_refined": false }, { "subclaim": "New pulmonary metastases were present.", "support_label": "supported", "is_refined": false }, { "subclaim": "A new effusion was present.", "support_label": "supported", "is_refined": false }, { "subclaim": "New bone metastases were present.", "support_label": "supported", "is_refined": false }, { "subclaim": "The patient was not considered fit for targeted therapy.", "support_label": "supported", "is_refined": false }, { "subclaim": "The patient died 5 months after the radiological progression.", "support_label": "supported", "is_refined": false } ] }, { "id": "multiclinsum_test_822_en.txt", "fulltext": "A 69-year-old woman presented with pericardial discomfort and was subsequently diagnosed with advanced gastric cancer after upper gastrointestinal endoscopy. The patient underwent laparoscopic distal gastrectomy with D2 lymph node dissection, and the final pathological diagnosis was U, Less, Type 2, 46 × 38 mm, adenocarcinoma with enteroblastic differentiation, pT4a, INFa, Ly0, V0, pPM0, pDM0, pN2, and pStageIIIA (Japanese Classification of Gastric Carcinoma) . Human epidermal growth factor type 2 was negative, combined positive score of programmed cell death ligand 1 was 5 or higher and microsatellite instability was negative. The patient received oral S-1 (80 mg/m2 twice a day for 1–28 days) as postoperative adjuvant chemotherapy, but liver metastases were observed 8 months later in segments 4 (41 × 39 mm) and 8 (24 × 22 mm). The location and number of metastases were confirmed by contrast-enhanced computed tomography (CT), magnetic resonance imaging (MRI) and positron emission tomography (PET)–CT. There was no elevation observed in the tumor markers carcinoembryonic antigen (CEA) and carbohydrate antigen 19-9 (CA19-9). The patient was switched to weekly paclitaxel plus ramucirumab, but Grade 4 neutropenia was observed during the first cycle, and nivolumab monotherapy was initiated (3 mg/kg intravenously every 2 weeks) after consultation with the patient .\nAfter eight cycles, the target lesion of liver metastasis achieved a PR by Response Evaluation Criteria in Solid Tumors (RECIST), and nivolumab treatment was continued. After 18 cycles, liver metastases had shrunk to 24 × 22 mm in segment 4 and 11 × 9 mm in segment 8, and PET–CT showed no abnormal fluorodeoxyglucose (FDG) accumulation in liver metastases, and no new metastases appeared. CEA and CA19-9 did not show any significant changes within the normal range during the course of treatment. However, at this point, the patient developed a Grade 3 immune-related adverse event (irAE), a pemphigoid skin disorder, and the nivolumab treatment was discontinued.\nAs the metastases were controllable with anticancer agents, no new lesions appeared, and the patient’s performance status was maintained, it was decided to resect the liver metastases. The patient underwent laparoscopic partial hepatectomy for segments 4 and 8, resulting in pathological CR . After a medication withdrawal period due to the surgery, the skin disorder had resolved, and postoperative chemotherapy with nivolumab was resumed. However, due to a recurrence of the skin disorder, the chemotherapy was immediately stopped. The patient was followed up without treatment, and no recurrence findings were observed for 25 months postoperatively.", "summary": "A 69-year-old female presented with pericardial discomfort and was diagnosed with advanced gastric cancer following upper gastrointestinal endoscopy. Laparoscopic distal gastrectomy with D2 lymph node dissection was performed, resulting in a final pathological diagnosis of Stage IIIA. The patient received postoperative adjuvant chemotherapy with oral S-1 therapy, but was found to have multiple liver metastases at 8 months postsurgery. Weekly paclitaxel and ramucirumab therapy was initiated, but the patient experienced adverse side effects, leading to the discontinuation of treatment. Nivolumab monotherapy was then administered for 18 cycles, resulting in a partial therapeutic response and PET-CT revealed a complete metabolic response. However, the patient developed a Grade 3 pemphigoid as an immune-related adverse event, leading to the cessation of nivolumab. The patient underwent laparoscopic partial hepatectomy. Postoperative pathology showed no residual tumor cells, indicating a complete response. At present, 25 months after surgery, the patient was alive without recurrence.", "subclaim_evaluations": [ { "subclaim": "The patient is a 69-year-old female.", "support_label": "supported", "is_refined": false }, { "subclaim": "She presented with pericardial discomfort.", "support_label": "supported", "is_refined": false }, { "subclaim": "She was diagnosed with advanced gastric cancer.", "support_label": "supported", "is_refined": false }, { "subclaim": "The diagnosis was made following upper gastrointestinal endoscopy.", "support_label": "supported", "is_refined": false }, { "subclaim": "Laparoscopic distal gastrectomy with D2 lymph node dissection was performed.", "support_label": "supported", "is_refined": false }, { "subclaim": "The final pathological diagnosis was Stage IIIA.", "support_label": "supported", "is_refined": false }, { "subclaim": "The patient received postoperative adjuvant chemotherapy with oral S-1 therapy.", "support_label": "supported", "is_refined": false }, { "subclaim": "Multiple liver metastases were found at 8 months postsurgery.", "support_label": "supported", "is_refined": false }, { "subclaim": "Weekly paclitaxel and ramucirumab therapy was initiated.", "support_label": "supported", "is_refined": false }, { "subclaim": "The patient experienced adverse side effects.", "support_label": "supported", "is_refined": false }, { "subclaim": "Treatment with paclitaxel and ramucirumab was discontinued.", "support_label": "supported", "is_refined": false }, { "subclaim": "Nivolumab monotherapy was administered for 18 cycles.", "support_label": "supported", "is_refined": false }, { "subclaim": "A partial therapeutic response was observed.", "support_label": "supported", "is_refined": false }, { "subclaim": "PET-CT revealed a complete metabolic response.", "support_label": "supported", "is_refined": false }, { "subclaim": "The patient developed a Grade 3 pemphigoid as an immune-related adverse event.", "support_label": "supported", "is_refined": false }, { "subclaim": "Nivolumab was discontinued.", "support_label": "supported", "is_refined": false }, { "subclaim": "The patient underwent laparoscopic partial hepatectomy.", "support_label": "supported", "is_refined": false }, { "subclaim": "Postoperative pathology showed no residual tumor cells.", "support_label": "supported", "is_refined": false }, { "subclaim": "The patient had a complete response.", "support_label": "supported", "is_refined": false }, { "subclaim": "The patient was alive without recurrence 25 months after surgery.", "support_label": "supported", "is_refined": false } ] }, { "id": "multiclinsum_test_1659_en.txt", "fulltext": "A 30 year old primagravid woman at 17 weeks gestation was found on routine prenatal ultrasound to have a complex right ovarian mass. She underwent surgery and was found to have a ruptured appendiceal mucinous neoplasm with a large volume pseudomyxoma peritonei syndrome. The right ovary and appendix were removed and an omental biopsy was performed. The final pathology confirmed a well-differentiated mucinous adenocarcinoma of appendiceal origin. She recovered without incident from this surgery and was referred for assessment to the Washington Hospital Center at 26 weeks gestation. In consultation with the patient and her obstetrician it was decided to preserve the pregnancy and schedule an early vaginal delivery at 35 weeks gestation.\nFollowing an uncomplicated vaginal delivery of a healthy baby, she underwent a staging CT. It showed no evidence of metastases within the liver parenchyma or outside of the peritoneal cavity. A large volume of mucinous cancer was imaged beneath right and left hemidiaphragm and in the pelvis. Small bowel except for the terminal ileum was spared. Preoperative tumor markers revealed an elevated CEA at 68.2 ng/mL (normal 0–5 ng/mL), CA-125 of 177 units/mL (normal 0–35 units/mL) and CA 19-9 of 361 units/mL (normal 0–37 units/mL).\nAt 2 1/2 weeks after delivery, the patient underwent an abdominal exploration followed by cytoreductive surgery. She had thick, densely packed tumor covering most of the parietal peritoneal surface, with an especially large volume of disease in the lesser omentum, omental bursa and surrounding the porta hepatis. The stomach and the small bowel except for the terminal ileum were spared. An extensive cytoreduction surgery was performed including total anterior parietal peritonectomy and resection of tumor in the abdominal wall scar, greater and lesser omentectomy with stripping of the omental bursa, right and left upper quadrant peritonectomies including total diaphragm stripping bilaterally, splenectomy, electroevaporation of tumor on liver capsule, cholecystectomy, and a right hemicolectomy including the distal 15 cm of terminal ileum. A total pelvic peritonectomy with abdominal hysterectomy, left salpingo-oophorectomy and rectosigmoid colon resection was performed. The peritoneal cancer index score was 28 (out of a maximum of 39), and the cytoreduction was scored as complete (residual tumor less than 2.5 mm) . Intraoperative intraperitoneal heated chemotherapy was administered through the open coliseum technique, with 15 mg/m2 mitomycin C at 41.5°C for 90 minutes. A Tenckhoff catheter and Jackson-Pratt drains were inserted for early postoperative intraperitoneal 5-fluorouracil chemotherapy . Following completion of the hyperthermic intraoperative intraperitoneal chemotherapy an ileocolic and colorectal anastomosis was performed. The total operating time was 9 hours, and the blood loss was estimated at 350 mL, with 2 units of packed red blood cells and 4 units of fresh frozen plasma administered during the operation.\nOn postoperative day 1 through 5, 900 mg intraperitoneal 5-fluorouracil in 1.5% dextrose peritoneal dialysis solution was administered daily for 23 hours. The patient developed uncomplicated neutropenia on postoperative day 16, with neutrophil count of 0.9 × 103/uL and a total leukocyte count of 1.3 × 103/uL, which was treated successfully with granulocyte colony stimulating factor. On postoperative day 18 she was diagnosed with a left lower extremity deep venous thrombosis and was treated with intravenous heparin which was converted to warfarin prior to discharge from the hospital. She had a postoperative ileus requiring nasogastric drainage for 2 weeks and received total parenteral nutrition during this time. She was discharged in good condition on postoperative day 24.\nThree weeks following surgery her tumor marker levels decreased with CEA at 0.5 ng/mL, CA 125 at 92.1 units/mL, and CA 19-9 at 10.6 units/mL. CA 125 normalized by 2 months post-operatively.\nAfter recovery from surgery, she was treated with the Xelox regimen (Xeloda 1000 mg/m2 bid for 14 days then 7 day rest and oxaliplatin 130 mg/m2 intravenous over 90 minutes on day 1) for 8 cycles over 24 weeks.\nIn follow-up at five years after, the patient and her child are in good condition. She has had two episodes of transient small bowel obstruction treated conservatively. On her most recent clinical, radiologic and biochemical assessment at 5 years after her initial diagnosis she remains disease-free.", "summary": "The medical history of a 30 year old woman diagnosed at 17 weeks gestation with an appendiceal mucinous tumor with large volume pseudomyxoma peritonei was presented. Her pregnancy was preserved and she had an early vaginal delivery of a healthy baby at 35 weeks. At 2 1/2 weeks postpartum the patient underwent extensive cytoreductive surgery and intraperitoneal chemotherapy. She remains disease-free 5 years after her initial diagnosis. A literature review of this clinical situation and a discussion of treatment plans were presented.", "subclaim_evaluations": [ { "subclaim": "The patient is a 30 year old woman.", "support_label": "supported", "is_refined": false }, { "subclaim": "She was diagnosed at 17 weeks gestation.", "support_label": "supported", "is_refined": false }, { "subclaim": "The diagnosis was an appendiceal mucinous tumor.", "support_label": "supported", "is_refined": false }, { "subclaim": "She had large volume pseudomyxoma peritonei.", "support_label": "supported", "is_refined": false }, { "subclaim": "Her pregnancy was preserved.", "support_label": "supported", "is_refined": false }, { "subclaim": "She had an early vaginal delivery.", "support_label": "supported", "is_refined": false }, { "subclaim": "The delivery occurred at 35 weeks.", "support_label": "supported", "is_refined": false }, { "subclaim": "The baby was healthy.", "support_label": "supported", "is_refined": false }, { "subclaim": "At 2 1/2 weeks postpartum, she underwent extensive cytoreductive surgery.", "support_label": "supported", "is_refined": false }, { "subclaim": "She received intraperitoneal chemotherapy.", "support_label": "supported", "is_refined": false }, { "subclaim": "She remains disease-free 5 years after her initial diagnosis.", "support_label": "supported", "is_refined": false }, { "subclaim": "A literature review of this clinical situation was presented.", "support_label": "not_supported", "original_label": "not_supported", "reasoning_audit": "No explicit tags provided.", "is_refined": true }, { "subclaim": "A discussion of treatment plans was presented.", "support_label": "supported", "is_refined": false } ] }, { "id": "multiclinsum_test_2476_en.txt", "fulltext": "A 28-year-old mestizo man with a 3-year history of inflammatory arthritis and dry mouth and eyes was admitted to our hospital. He was admitted to our hospital at the request of an external consultant in January 2008; the initial laboratory evaluation is listed in Table . Methotrexate was initiated with good response; 1 year later methotrexate was changed to leflunomide because of liver toxicity. Globulin levels at admission and 1 year after were 5.2 and 7.2g/dL, respectively. Of interest, although he also had positive anti-double-stranded deoxyribonucleic acid (DNA) and anti-nucleosomes antibodies, which normally have a higher specificity for the diagnosis of SLE, at admission we could not make a diagnosis because of the absence of clinical manifestations other than arthritis and sicca.\nHyperemia and mild eye pain appeared in March 2009, and a diffuse scleritis was diagnosed. Therefore leflunomide was suspended and he received prednisone (1mg/kg), tapered to 5mg/day in 1 month and suspended after another month because a mouth ulcer appeared.\nMultiple important mucosal bleeding episodes (epistaxis and gingival hemorrhage) started in 2009, and coagulation tests were conducted through 2010, with the following results: prothrombin time, international normalized ratio and activated partial thromboplastin times were normal (11/10.4 seconds; 1.2; 31.1/26.9 seconds, respectively), VWF activity was observed with low ristocetin cofactor (RCo) at 33.6UI/dL, high VWF antigen (VWF:Ag) >200UI/dL, and a low VWF:RCo to VWF:Ag ratio. Furthermore, an Ivy bleeding time test of more than 15 minutes and normal factor VIII activity (70UI/dL) were observed. An in vitro test showed that the patient’s IgG inhibited the VWF:RCo of normal plasma, therefore the RCo activity inhibition test was positive, although this was not necessary for the diagnosis. A characteristic aVWD laboratory test with the identification of a causal underlying disease, integrated the diagnosis .\nThe patient was admitted to the ER in April 2011 with a 24-hour evolution of progressive dyspnea, cough, thoracic pain, and palpitations, 104beats/minute, 60/40mmHg, temperature of 38°C, pulse oximetric saturation 88% and 30 breaths/minute. Cold, pale and mottled skin was also observed; laboratory values at ER admission are listed in Table . There were no signs of arthritis or bleeding. Initial crystalloid reanimation was made with partial response, and persistent tachypnea and hypoxemia (arterial oxygen tension/fraction of inspired oxygen = 245.7) precluded a rapid intubation sequence. He was then transferred to the intensive care unit (ICU) 12 hours later. Initial laboratory ER patient data are listed in Table ; Acute Physiology and Chronic Health Evaluation II and Sequential Organ Failure Assessment values at ICU admission were 11 and 27 points respectively.\nAn electrocardiogram showed an incomplete right bundle block not previously detected. A chest X-ray revealed no infiltrates, and complementary laboratory tests did not suggest a related infection. The placement of a pulmonary artery catheter (PAC) was made under the indication of a differentiation between cardiogenic and non-cardiogenic shock (see Table ). The initial patterns showed a precapillary pulmonary hypertension; therefore, in the autoimmune context of the patient, although serial negative antiphospholipid antibodies were noted in his history, acute pulmonary embolism was the first choice for diagnosis. Pulmonary angiography was conducted, and when no clot was discovered, PAH associated with connective tissue disease was considered because pulmonary hypertension has been historically associated with connective tissue diseases.\nThese PAC parameters were the same as observed by Condliffe et al. and Murata et al. except for the pulmonary vascular resistance index, which was greater in our patient in comparison to the Condliffe et al. cases (715 versus 1525 dyne·second/(cm5·m2)). Because connective tissue disease may cause PAH because of the vasculature pathology, the difference in more severe resistance may be explained by the changes in the rheological properties (1 poise (P) = 1g·(second·cm)-1 = 1dyne·second/cm2) present in the HVS, where a decrease in the blood flow can explain the resistance increase. Laboratory blood samples hinted about the thickness of blood, so viscosity was measured and found to be 65.8cP (<1.9cP).\nLymphadenopathy and organomegaly were ruled out. A bone marrow biopsy did not show clonality of plasma cells. Serum protein electrophoresis confirmed the presence of a massive polyclonal hypergammaglobulinemia, and no paraproteinemia or monoclonal cell population was found from the electrophoretic pattern of the patient’s plasma. Hypergammaglobulinemia was the cause of HVS associated with autoantibodies. Three sessions of plasma exchange therapy were made. Albumin and frozen fresh plasma were used as the expander, and one circulating blood volume was utilized. Significant mental, hemodynamic recovery and clinical outcomes became evident. A negative Q value was observed in the HVS in this patient after taking into account the Starling vascular permeability formula, where the microvasculature is influenced by protein content and transcapillary fluid flux, specifically, where Q is equal to volume of flow across the capillary wall. This finding led to the conclusion that dilution of protein content may alleviate the HVS, and the fluid administration was considered supportive therapy with judicious consideration of the compartment shift of the solutions. His renal function returned to basal state and he was extubated on day 7 of ICU admission. He was then discharged from the ICU and hospital, respectively with good prognosis (Charlson comorbidity index of 0 points).\nThe patient now attends external consult without respiratory symptoms. One month after hospital discharge his arthritis returned and methotrexate was resumed with good clinical response. Hydroxychloroquine with steroids were initiated because of persistent elevated anti-double stranded DNA (last value at February 2013, 20.2U/mL), no bleeding sign had been present with persistent positive VWF:Ag values.", "summary": "A 28-year-old mestizo man with a 3-year history of inflammatory arthritis was admitted to our hospital. An overlap of rheumatoid arthritis with systemic lupus erythematosus was suspected; therefore methotrexate was initiated, and later changed to leflunomide because of liver toxicity. Prothrombin time, international normalized ratio and activated partial thromboplastin times were normal (11/10.4 seconds; 1.2; 31.1/26.9 seconds, respectively), von Willebrand factor activity was observed with low ristocetin cofactor at 33.6UI/dL, high von Willebrand factor antigen >200UI/dL, and a low von Willebrand factor: ristocetin cofactor to von Willebrand factor antigen ratio. He was admitted to the emergency room with a 24-hour evolution of progressive dyspnea, cough, thoracic pain, and palpitations, 104 beats/min, 60/40 mmHg, temperature of 38°C, pulse oximetric saturation 88% and 30 breaths/minute. Cold, pale and mottled skin was also observed. He was then transferred to the intensive care unit. The placement of a pulmonary artery catheter was made. The initial patterns showed a precapillary pulmonary hypertension; acute pulmonary embolism was the first choice for diagnosis. Pulmonary angiography was conducted, and when no clot was discovered, pulmonary artery hypertension associated with connective tissue disease was considered. Serum protein electrophoresis confirmed the presence of a massive polyclonal hypergammaglobulinemia, and no paraproteinemia or monoclonal cell population was found from the electrophoretic pattern of the patient's plasma. Hypergammaglobulinemia was the cause of hyperviscosity syndrome associated with autoantibodies. Three sessions of plasma exchange therapy were made, and clinical improvement was observed. He was then discharged from the intensive care unit and hospital, respectively. He is now attended by an external consult and has no respiratory symptomatology.", "subclaim_evaluations": [ { "subclaim": "The patient is a 28-year-old mestizo man.", "support_label": "supported", "is_refined": false }, { "subclaim": "He has a 3-year history of inflammatory arthritis.", "support_label": "supported", "is_refined": false }, { "subclaim": "An overlap of rheumatoid arthritis with systemic lupus erythematosus was suspected.", "support_label": "supported", "is_refined": false }, { "subclaim": "Methotrexate was initiated.", "support_label": "supported", "is_refined": false }, { "subclaim": "Methotrexate was later changed to leflunomide.", "support_label": "supported", "is_refined": false }, { "subclaim": "The change was due to liver toxicity.", "support_label": "supported", "is_refined": false }, { "subclaim": "Prothrombin time was 11 seconds.", "support_label": "supported", "is_refined": false }, { "subclaim": "International normalized ratio was 1.2.", "support_label": "supported", "is_refined": false }, { "subclaim": "Activated partial thromboplastin time was 31.1 seconds.", "support_label": "supported", "is_refined": false }, { "subclaim": "Von Willebrand factor activity was observed.", "support_label": "supported", "is_refined": false }, { "subclaim": "Ristocetin cofactor was 33.6UI/dL.", "support_label": "supported", "is_refined": false }, { "subclaim": "Von Willebrand factor antigen was greater than 200UI/dL.", "support_label": "supported", "is_refined": false }, { "subclaim": "The patient was admitted to the emergency room.", "support_label": "supported", "is_refined": false }, { "subclaim": "He had progressive dyspnea.", "support_label": "supported", "is_refined": false }, { "subclaim": "He had a 24-hour evolution of symptoms.", "support_label": "supported", "is_refined": false }, { "subclaim": "He had a temperature of 38°C.", "support_label": "supported", "is_refined": false }, { "subclaim": "Pulse oximetric saturation was 88%.", "support_label": "supported", "is_refined": false }, { "subclaim": "He had cold, pale, and mottled skin.", "support_label": "supported", "is_refined": false }, { "subclaim": "He was transferred to the intensive care unit.", "support_label": "supported", "is_refined": false }, { "subclaim": "A pulmonary artery catheter was placed.", "support_label": "supported", "is_refined": false }, { "subclaim": "Initial patterns showed precapillary pulmonary hypertension.", "support_label": "supported", "is_refined": false }, { "subclaim": "Acute pulmonary embolism was the first choice for diagnosis.", "support_label": "supported", "is_refined": false }, { "subclaim": "Pulmonary angiography was conducted.", "support_label": "supported", "is_refined": false }, { "subclaim": "No clot was discovered.", "support_label": "supported", "is_refined": false }, { "subclaim": "Pulmonary artery hypertension associated with connective tissue disease was considered.", "support_label": "supported", "is_refined": false }, { "subclaim": "Serum protein electrophoresis confirmed massive polyclonal hypergammaglobulinemia.", "support_label": "supported", "is_refined": false }, { "subclaim": "No paraproteinemia was found.", "support_label": "supported", "is_refined": false }, { "subclaim": "No monoclonal cell population was found.", "support_label": "supported", "is_refined": false }, { "subclaim": "Hypergammaglobulinemia was the cause of hyperviscosity syndrome.", "support_label": "supported", "is_refined": false }, { "subclaim": "Three sessions of plasma exchange therapy were made.", "support_label": "supported", "is_refined": false }, { "subclaim": "Clinical improvement was observed.", "support_label": "supported", "is_refined": false }, { "subclaim": "He was discharged from the intensive care unit.", "support_label": "supported", "is_refined": false }, { "subclaim": "He was discharged from the hospital.", "support_label": "supported", "is_refined": false }, { "subclaim": "He is now attended by an external consult.", "support_label": "supported", "is_refined": false }, { "subclaim": "He has no respiratory symptomatology.", "support_label": "supported", "is_refined": false } ] }, { "id": "multiclinsum_test_75_en.txt", "fulltext": "A 63-year-old male presented to the First Hospital of Jilin University with a 2-month history of a cervical mass. He had no history of neoplasms and no family history of tumors. Blood tests showed slightly increased thyroid stimulating hormone levels (56 μIU/mL) and decreased T3 (2.4 pmol/L) and T4 (10 pmol/L) levels. His antithyroglobulin antibody levels were within the normal range. Computed tomography imaging showed a mass, approximately 4.5 × 4.0 × 4.5 cm in size, with calcification in the left thyroid lobe and two smooth and homogeneous nodules in the right thyroid lobe. The trachea was compressed and deflected toward the left side . The patient underwent total thyroidectomy with cervical lymph node resection. Neck MRI showed that the epicenter of the left lobe mass was in the thyroid gland and that it did not originate from the surrounding thyroid cartilage .\nMacroscopic examination of the resected specimen revealed a lobulated mass with calcification that occupied the majority of the left thyroid lobe and two homogeneous, oval nodules in the right thyroid lobe .\nHistopathologically, the majority of the tumor in the left thyroid lobe comprised low-grade hyaline-type cartilage, and some spindle cells were observed around the hyaline cartilage . In some areas, the tumor infiltrated the remaining thyroid tissue . A high-grade spindle cell sarcoma could be seen in some areas , in which the high-grade sarcoma cells exhibited extensive pleomorphism, atypia, and a high mitotic rate . One of the two nodules in the right thyroid lobe had a gray-white appearance, and it comprised a prominently collagenous stroma and some bland spindle cells infiltrating the surrounding thyroid tissue . The other nodule had a brown appearance; it was completely enclosed within a thin, fibrous capsule and exhibited normofollicular and microfollicular architecture . We carefully examined all hematoxylin and eosin–stained sections; however, we did not observe any definite necrosis.\nTable shows the summary of immunohistochemical findings. The spindle tumor cells in both thyroid lobes were positive for vimentin but negative for cytokeratin and epithelial membrane antigen. These spindle cells showed high expression of Ki-67 . The low-grade hyaline-type cartilage in the left thyroid tumor was positive for vimentin . The positive rate of expression of vimentin in both the thyroid tumors was 90%. The positive rate of expression of Ki-67 in the spindle cells of the left thyroid tumor was 50%. The positive rate of expression of Ki-67 in the spindle cells of the right thyroid gray-white nodule was 20%.\nThe patient received postoperative radiotherapy and was free of local and regional recurrence or distant metastases at the 8-month follow-up evaluation.", "summary": "Computed tomography imaging of a 63-year-old male with a 2-month history of a cervical mass revealed a 4.5-cm lesion with heterogeneous enhancement in the left thyroid lobe and two smooth and homogeneous nodules in the right thyroid lobe. The patient underwent total thyroidectomy and cervical lymph node resection. Histologically, the tumor boundary in the left lobe was clear, with a few mitotically active, spindle sarcoma-like tumor cells observed in some areas. Immunohistochemically, these spindle cells were positive for vimentin and negative for cytokeratin, paired box-8, epithelial membrane antigen, calcitonin, thyroglobulin, and thyroid transcription factor-1. In other areas, abundant cartilage matrix production and irregularly shaped lobules of cartilage, often separated by fibrous bands, were observed. The chondrocytes appeared mildly/moderately atypical and contained enlarged, hyperchromatic nucleoli. One of the two nodules in the right thyroid lobe had a clear boundary and comprised some bland spindle cells in a prominently collagenous stroma with clear boundaries. The other nodule in the right thyroid lobe was completely enclosed within a thin, fibrous capsule and exhibited normofollicular and microfollicular architecture. The patient received adjuvant radiotherapy after the surgery and was free of any local or regional recurrence or distant metastases at the 8-month follow-up evaluation.", "subclaim_evaluations": [ { "subclaim": "The patient is a 63-year-old male.", "support_label": "supported", "is_refined": false }, { "subclaim": "The patient had a 2-month history of a cervical mass.", "support_label": "supported", "is_refined": false }, { "subclaim": "Computed tomography imaging showed a 4.5-cm lesion in the left thyroid lobe.", "support_label": "supported", "is_refined": false }, { "subclaim": "The lesion in the left thyroid lobe had heterogeneous enhancement.", "support_label": "not_supported", "original_label": "not_supported", "reasoning_audit": "No explicit tags provided.", "is_refined": true }, { "subclaim": "There were two smooth and homogeneous nodules in the right thyroid lobe.", "support_label": "supported", "is_refined": false }, { "subclaim": "The patient underwent total thyroidectomy.", "support_label": "supported", "is_refined": false }, { "subclaim": "The patient underwent cervical lymph node resection.", "support_label": "supported", "is_refined": false }, { "subclaim": "Histologically, the tumor boundary in the left lobe was clear.", "support_label": "not_supported", "original_label": "not_supported", "reasoning_audit": "No explicit tags provided.", "is_refined": true }, { "subclaim": "Some areas of the tumor contained mitotically active, spindle sarcoma-like tumor cells.", "support_label": "supported", "is_refined": false }, { "subclaim": "The spindle cells were positive for vimentin.", "support_label": "supported", "is_refined": false }, { "subclaim": "The spindle cells were negative for cytokeratin.", "support_label": "supported", "is_refined": false }, { "subclaim": "The spindle cells were negative for paired box-8.", "support_label": "not_supported", "original_label": "not_supported", "reasoning_audit": "No explicit tags provided.", "is_refined": true }, { "subclaim": "The spindle cells were negative for epithelial membrane antigen.", "support_label": "supported", "is_refined": false }, { "subclaim": "The spindle cells were negative for calcitonin.", "support_label": "not_supported", "original_label": "not_supported", "reasoning_audit": "No explicit tags provided.", "is_refined": true }, { "subclaim": "The spindle cells were negative for thyroglobulin.", "support_label": "supported", "is_refined": false }, { "subclaim": "The spindle cells were negative for thyroid transcription factor-1.", "support_label": "not_supported", "original_label": "not_supported", "reasoning_audit": "No explicit tags provided.", "is_refined": true }, { "subclaim": "Abundant cartilage matrix production was observed in some areas.", "support_label": "supported", "is_refined": false }, { "subclaim": "Irregularly shaped lobules of cartilage were observed.", "support_label": "supported", "is_refined": false }, { "subclaim": "The chondrocytes appeared mildly/moderately atypical.", "support_label": "supported", "is_refined": false }, { "subclaim": "The chondrocytes contained enlarged, hyperchromatic nucleoli.", "support_label": "not_supported", "original_label": "not_supported", "reasoning_audit": "No explicit tags provided.", "is_refined": true }, { "subclaim": "One of the two nodules in the right thyroid lobe had a clear boundary.", "support_label": "supported", "is_refined": false }, { "subclaim": "The nodule with a clear boundary comprised some bland spindle cells.", "support_label": "supported", "is_refined": false }, { "subclaim": "The nodule with a clear boundary had a prominently collagenous stroma.", "support_label": "supported", "is_refined": false }, { "subclaim": "The other nodule in the right thyroid lobe was completely enclosed within a thin, fibrous capsule.", "support_label": "supported", "is_refined": false }, { "subclaim": "The other nodule exhibited normofollicular and microfollicular architecture.", "support_label": "supported", "is_refined": false }, { "subclaim": "The patient received adjuvant radiotherapy after the surgery.", "support_label": "supported", "is_refined": false }, { "subclaim": "The patient was free of local recurrence at the 8-month follow-up.", "support_label": "supported", "is_refined": false }, { "subclaim": "The patient was free of regional recurrence at the 8-month follow-up.", "support_label": "supported", "is_refined": false }, { "subclaim": "The patient was free of distant metastases at the 8-month follow-up.", "support_label": "supported", "is_refined": false } ] }, { "id": "multiclinsum_test_719_en.txt", "fulltext": "A 49-year-old man presented with exertional dyspnea. Physical examination revealed a loud S1 and a diastolic murmur in the apical region. Transthoracic echocardiography revealed severe rheumatic MS with mild MR, as well as mild functional tricuspid regurgitation and a pulmonary pressure of 55 mmHg. Then, the patient underwent a three-dimensional transesophageal echocardiography to assess the mitral apparatus more accurately and exclude the presence of left atrial appendage thrombus . His Wilkins score was 8. This is a borderline score to take BMV. However, the patient prefers to take the percutaneous intervention rather than thoracotomy. Thus, BMV was performed via the antegrade approach under local anesthesia and X-ray fluoroscopy guidance. After transseptal puncture, a 24-mm balloon was used to achieve a single dilatation of 22 mm, after which the mean transmitral pressure gradient decreased from 19 to 11 mmHg. Intraoperative transthoracic echocardiography performed immediately afterwards revealed a significant increase in mitral regurgitation. However, the subvalvular structure could not be observed clearly because the patient was in a supine position. His vital signs remained stable with no definite symptoms, and he refused mitral valve replacement. He was discharged 4 days later after undergoing BMV. Two-dimensional transthoracic echocardiography follow-up performed one month later revealed severe MR caused by a freely mobile part of the mitral papillary muscle . The left ventricular cavity and the two groups of papillary muscle were then imaged using three-dimensional transthoracic echocardiography, which showed avulsion of the posterior papillary muscle (PMA) from the left ventricular trabecular muscle. No residual papillary muscle attachment to the left ventricular wall was observed, confirming avulsion of the posterior papillary rather than its rupture . In addition, the left ventricular end-diastolic dimension increased from 45 to 53 mm. The estimated systolic pulmonary pressure increased from 55 mmHg to 81 mmHg. Therefore, the patient underwent mechanical mitral valve replacement and tricuspid annuloplasty. After surgery, the patient recovered without symptoms. At 1-month and three-month follow ups, the patient was asymptomatic, and transthoracic echocardiography showed that the left ventricular volume and pulmonary systolic pressure were significantly lower than before surgery.", "summary": "In this case report, we describe a patient with rheumatic mitral stenosis, who experienced avulsion of the mitral papillary muscle from the left ventricular wall after undergoing balloon mitral valvotomy. Papillary muscle alvusion resulted in severe mitral regurgitation, which was finally treated by mitral valve replacement.", "subclaim_evaluations": [ { "subclaim": "The patient had rheumatic mitral stenosis.", "support_label": "supported", "is_refined": false }, { "subclaim": "The patient underwent balloon mitral valvotomy.", "support_label": "supported", "is_refined": false }, { "subclaim": "The patient experienced avulsion of the mitral papillary muscle from the left ventricular wall.", "support_label": "supported", "is_refined": false }, { "subclaim": "The avulsion occurred after balloon mitral valvotomy.", "support_label": "supported", "is_refined": false }, { "subclaim": "Papillary muscle avulsion resulted in severe mitral regurgitation.", "support_label": "supported", "is_refined": false }, { "subclaim": "The severe mitral regurgitation was treated by mitral valve replacement.", "support_label": "supported", "is_refined": false } ] }, { "id": "multiclinsum_test_486_en.txt", "fulltext": "A 26-year-old Japanese male presented with severe headache and nausea for approximately 3 weeks. He had a prior episode of suspected convulsion of which magnetic resonance imaging (MRI) revealed a cystic nodular lesion measuring approximately 60 mm in diameter, located in the left parietal lobe of the cerebrum. The patient was administered medication, and symptoms were subsequently relieved. However, 12 days later, he experienced worsened symptoms and was transferred and admitted to the emergency department of the University of Miyazaki Hospital.\nMRI showed a mass of 70 × 53 × 57 mm in the left temporoparietal lobe . A solid element with slight hypointensity on T1-weighted and hyperintensity on T2-weighted images along the dura mater was noted. Cystic changes were likely associated with the sanguineous fluid. A peritumoral band with hyperintensity on T2-weighted image was observed at the periphery of the lesion, suggesting an extra-axial lesion . A dural tail sign was also noted on the gadolinium-enhanced T1-weighted image . The lesion appeared to be focally infiltrative to the brain surface, but no apparent connection to the ventricle was observed . Preoperative clinical diagnosis was meningioma, but hemangiopericytoma and ependymoma were included as differential diagnoses. Left parietotemporal craniotomy was performed. The tumor was an extra-axial mass and had partially infiltrated the dura mater and surface of the brain parenchyma in the left temporal lobe. Small pieces of tumor tissue were removed for intraoperative diagnosis. Under an emergency setting, near-total resection was achieved even if the lesion was in the eloquent area. The patient received postoperative adjuvant radiotherapy (total dose 54 Gy). However, within 1 year postsurgery, the tumor recurred and a second resection surgery was performed. Four years after the first surgery, the tumor metastasized to the spinal cord and the patient eventually died (total postoperative follow-up period was 4 years and 4 months).", "summary": "A 26-year-old Japanese man with headache and nausea was referred to our medical facility. Magnetic resonance imaging revealed a cystic mass of 70 × 53 × 57 mm in the left temporoparietal lobe. A peritumoral band with hyperintensity on T2-weighted imaging was observed at the periphery of the lesion, suggesting an extra-axial lesion with no apparent connection to the ventricle. A dural tail sign was also noted on the gadolinium-enhanced T1-weighted image. Preoperative clinical diagnosis was meningioma. Proliferated tumor cells in sheets with intermingled branching vessels were observed in the frozen tissue. Perivascular rosettes were inconspicuous, and the tumor cells had rhabdoid cytoplasm. The tumor was intraoperatively diagnosed as a meningioma, suspected to be a rhabdoid meningioma. Perivascular rosettes were evident in the formalin-fixed paraffin-embedded tissues, suggesting ependymoma. The tumor cells had eosinophilic cytoplasm without a rhabdoid appearance. Anaplastic features, such as high tumor cellularity, increased mitotic activity, microvascular proliferation, and necrosis, were observed. Ependymal differentiation was confirmed on the basis of ultrastructural analysis. Molecular analysis detected C11orf95-RELA fusion gene. The final diagnosis was RELA fusion-positive ependymoma, World Health Organization grade III.", "subclaim_evaluations": [ { "subclaim": "The patient is a 26-year-old Japanese man.", "support_label": "supported", "is_refined": false }, { "subclaim": "The patient had headache.", "support_label": "supported", "is_refined": false }, { "subclaim": "The patient had nausea.", "support_label": "supported", "is_refined": false }, { "subclaim": "Magnetic resonance imaging revealed a cystic mass in the left temporoparietal lobe.", "support_label": "supported", "is_refined": false }, { "subclaim": "The mass measured 70 × 53 × 57 mm.", "support_label": "supported", "is_refined": false }, { "subclaim": "A peritumoral band with hyperintensity on T2-weighted imaging was observed.", "support_label": "supported", "is_refined": false }, { "subclaim": "The lesion was suggested to be extra-axial.", "support_label": "supported", "is_refined": false }, { "subclaim": "The lesion had no apparent connection to the ventricle.", "support_label": "supported", "is_refined": false }, { "subclaim": "A dural tail sign was noted on the gadolinium-enhanced T1-weighted image.", "support_label": "supported", "is_refined": false }, { "subclaim": "The preoperative clinical diagnosis was meningioma.", "support_label": "supported", "is_refined": false }, { "subclaim": "Proliferated tumor cells in sheets were observed in the frozen tissue.", "support_label": "supported", "is_refined": false }, { "subclaim": "The tumor cells had rhabdoid cytoplasm.", "support_label": "not_supported", "original_label": "not_supported", "reasoning_audit": "No explicit tags provided.", "is_refined": true }, { "subclaim": "The tumor was intraoperatively diagnosed as meningioma.", "support_label": "supported", "is_refined": false }, { "subclaim": "The tumor was suspected to be a rhabdoid meningioma.", "support_label": "not_supported", "original_label": "not_supported", "reasoning_audit": "No explicit tags provided.", "is_refined": true }, { "subclaim": "Perivascular rosettes were evident in the formalin-fixed paraffin-embedded tissues.", "support_label": "not_supported", "original_label": "not_supported", "reasoning_audit": "No explicit tags provided.", "is_refined": true }, { "subclaim": "The tumor cells had eosinophilic cytoplasm.", "support_label": "not_supported", "original_label": "not_supported", "reasoning_audit": "No explicit tags provided.", "is_refined": true }, { "subclaim": "Anaplastic features were observed.", "support_label": "not_supported", "original_label": "not_supported", "reasoning_audit": "No explicit tags provided.", "is_refined": true }, { "subclaim": "Ependymal differentiation was confirmed by ultrastructural analysis.", "support_label": "not_supported", "original_label": "not_supported", "reasoning_audit": "No explicit tags provided.", "is_refined": true }, { "subclaim": "Molecular analysis detected C11orf95-RELA fusion gene.", "support_label": "not_supported", "original_label": "not_supported", "reasoning_audit": "No explicit tags provided.", "is_refined": true }, { "subclaim": "The final diagnosis was RELA fusion-positive ependymoma.", "support_label": "not_supported", "original_label": "not_supported", "reasoning_audit": "No explicit tags provided.", "is_refined": true }, { "subclaim": "The tumor was classified as World Health Organization grade III.", "support_label": "not_supported", "original_label": "not_supported", "reasoning_audit": "No explicit tags provided.", "is_refined": true } ] }, { "id": "multiclinsum_test_1784_en.txt", "fulltext": "We report the case of a 48-year-old female who checked into the emergency room (ER) having experienced pain in her chest and left shoulder since the previous evening. The patient was of normal weight and reported a positive family history for coronary artery disease, but denied other cardiovascular risk factors such as hypercholesterinaemia, hypertension, diabetes, or nicotine consumption. The patient had no past medical history and was taking no medication. At presentation, her vital signs were stable. The physical and cardiovascular examination revealed no abnormalities. The chest pain receded after one gram of paracetamol.\nA 12-lead electrocardiogram (ECG) was performed in the ER at presentation, showing inverted T-waves in II, III, aVF, V4, V5, and V6 . Bedside echocardiography revealed hypokinesis in the apical inferior segment of the left ventricle. The laboratory results showed significantly increased values for high-sensitivity troponin I (upward of 25 000 pg/mL, reference range: 0.0–51.4 pg/mL) and creatine kinase (CK) (540 U/L, reference range: 0–145 U/L). Therefore, a non-ST-elevation myocardial infarction was suspected, and the local interventional cardiology centre was contacted to perform coronary angiography (CAG).\nThe patient was swabbed before transfer to exclude a SARS-CoV-2 infection, as per the Medical University of Innsbruck (MUI) guidelines during the SARS-CoV-2 pandemic; surprisingly she tested positive for SARS-CoV-2 on the real-time reverse transcriptase-polymerase chain reaction assay. After further questioning, she reported having experienced isolated throat discomfort since the beginning of February, but denied contact with individuals with confirmed infections or flu-like symptoms; she also denied fever, cough, malaise, dyspnoea, or anosmia.\nAfter further discussion with the cardiology department, the ER team revised the working diagnosis to viral myocarditis and referred the patient to our infectious diseases ward, where she was promptly isolated and received cardiac and haemodynamic monitoring. We started therapy with acetylsalicylic acid, prophylactic-dose low-molecular-weight heparin, a statin, and a proton-pump inhibitor.\nA computed tomography coronary angiography (CTCA) was performed to exclude a coronary origin for the complaints and for the laboratory and ECG abnormalities, which revealed no significant coronary obstruction (Coronary Artery Disease Reporting and Data System: 0; Coronary Artery Calcium – Data and Reporting System: 0) .\nTo further confirm the diagnosis of viral myocarditis, a cardiac magnetic resonance imaging (CMR) was arranged. Surprisingly, CMR showed features of myocardial oedema restricted to the mid-ventricular to apical territory of the right coronary artery (RCA), as evidenced on T2 short tau inversion recovery sequence (signal intensity ratio of myocardium over skeletal muscle 2.3, ) and on T1 maps (increased native T1 of 1313 ms at inferior wall; reference value 980 ms, ). Based on subendocardial to partially transmural late gadolinium enhancement in the mid-ventricular to apical inferior wall, an acute myocardial infarction was diagnosed .\nMeanwhile, troponin T and CK values decreased , and episodes of mild chest pain were sufficiently controlled with paracetamol.\nAfter further communication with our interventional cardiology department the diagnosis was revised to a posterior MINOCA; the cardiologists advised against a CAG, due to the absence of coronary obstruction on the CTCA scan.\nFurther diagnostics with cardiac positron emission tomography–computed tomography showed evidence of reduced metabolic activity in the area affected by the infarction .\nWe prescribed dual anti-platelet therapy and an angiotensin-converting-enzyme inhibitor. A beta-blocker was not started due to a resting heart rate of 60 beats per minute. After two negative SARS-CoV-2 swab results in over 24 h and absence of COVID-19 typical symptoms, the patient was no longer considered infectious and could be assigned to a cardiac rehabilitation program. Follow-up echocardiography 2 days after discharge revealed a normal ejection fraction (58%) despite persistent inferior apical akinesia.", "summary": "A 48-year-old female, presenting with chest pain radiating to her left shoulder with no cardiovascular risk factors other than genetic predisposition, was screened for Severe Acute Respiratory Syndrome Coronavirus 2 (SARS-CoV-2) and tested positive. Although computed tomography angiography excluded obstructive coronary heart disease, cardiac magnetic resonance imaging showed an acute myocardial infarction with no obstructive coronary arteries of the inferior wall. The patient was treated with dual anti-platelet therapy, an angiotensin-converting-enzyme inhibitor and a statin, and assigned to a cardiac rehabilitation program.", "subclaim_evaluations": [ { "subclaim": "The patient is a 48-year-old female.", "support_label": "supported", "is_refined": false }, { "subclaim": "The patient had chest pain radiating to her left shoulder.", "support_label": "supported", "is_refined": false }, { "subclaim": "The patient had no cardiovascular risk factors other than genetic predisposition.", "support_label": "supported", "is_refined": false }, { "subclaim": "The patient was screened for SARS-CoV-2.", "support_label": "supported", "is_refined": false }, { "subclaim": "The patient tested positive for SARS-CoV-2.", "support_label": "supported", "is_refined": false }, { "subclaim": "Computed tomography angiography excluded obstructive coronary heart disease.", "support_label": "supported", "is_refined": false }, { "subclaim": "Cardiac magnetic resonance imaging showed an acute myocardial infarction.", "support_label": "supported", "is_refined": false }, { "subclaim": "The myocardial infarction involved the inferior wall.", "support_label": "supported", "is_refined": false }, { "subclaim": "The myocardial infarction occurred with no obstructive coronary arteries.", "support_label": "supported", "is_refined": false }, { "subclaim": "The patient was treated with dual anti-platelet therapy.", "support_label": "supported", "is_refined": false }, { "subclaim": "The patient was treated with an angiotensin-converting-enzyme inhibitor.", "support_label": "supported", "is_refined": false }, { "subclaim": "The patient was treated with a statin.", "support_label": "supported", "is_refined": false }, { "subclaim": "The patient was assigned to a cardiac rehabilitation program.", "support_label": "supported", "is_refined": false } ] }, { "id": "multiclinsum_test_3270_en.txt", "fulltext": "A Japanese 11-month-old baby boy presented at our institution with symptoms including fever, weight loss, and gallop rhythm. His fever persisted for 3 days before presentation but no treatment was provided. He was born by vaginal delivery at 37 weeks of gestation with a weight of 2612 g (36th percentile) and a head circumference of 33.7 cm. There was no family history of aortic disease and sudden death. When he was 7-months old, he had a fever of unknown origin that persisted for 2 weeks. He was poor in weight gain and was 7.55 kg (6th percentile) at the age of 10 months; his body weight decreased by 0.57 kg in the 3 weeks before presentation.\n\nOn examination at the presentation, his height was 70.8 cm, his weight was 6.98 kg, and his head circumference was 43 cm. He was ill-appearing and febrile to 38.4 °C. His blood pressure was 124/62 mmHg and pulse 146/minute. There was a notable S3 gallop and systolic murmur at the apex (Levine scale grade III/VI); however, there were no signs of rales or peripheral edema. Other physical and neurological examinations were normal. A chest X-ray revealed cardiomegaly, with 58% cardiothoracic rate. Echocardiography indicated left ventricular (LV) enlargement and dysfunction with LV diastolic dimension of 32 mm (130% of normal), LV ejection fraction 48%, moderate mitral regurgitation, and slight aortic regurgitation. Blood tests indicated the following: white blood cell count, 11.07 × 103/μl; hemoglobin, 10.6 g/dl; C-reactive protein, 5.59 mg/dl; creatine phosphokinase, 294 U/l; creatine phosphokinase-MB isozyme, 27 U/l; fibrin degradation products D-dimer, 2.1 μg/ml; brain natriuretic peptide, 2841 pg/ml; human atrial natriuretic peptide, 1360 pg/ml; and serum troponin T, 0.26 ng/ml. His blood culture at admission was negative.\n\nAs dilated cardiomyopathy was diagnosed, we initiated diuretics. However, his fever and high blood pressure (systolic blood pressure, 130–140 mmHg), which rarely present with dilated cardiomyopathy, persisted. To investigate the causes of high blood pressure, computed tomography was performed and revealed thoracic and abdominal aortic aneurysms on hospital day 3. It also revealed severe celiac artery stenosis and bilateral renal artery stenosis. From these findings, TA was diagnosed and 1 mg/kg per day prednisolone was consequently initiated as first-line therapy. His fever had resolved on day 5; his C-reactive protein levels returned to normal on day 10.\n\nAlthough his general condition improved, deterioration of vascular lesions was evident, as shown by echocardiography, on day 15. Celiac artery occlusion, severe right renal artery stenosis, and new superior mesenteric artery stenosis were also observed on day 15. We increased the dose of prednisolone to 2 mg/kg per day for 1 week due to the possibility of active inflammation around vascular lesions. In addition, we attempted continuous intravenous infusion of lipo-PGE1 at 10 ng/kg per minute to suppress the progression of angiostenosis. We performed vascular echocardiography twice a week and confirmed that there was no progression of angiostenosis following initiation of lipo-PGE1. We terminated infusion of lipo-PGE1 on day 36 and performed cardiac catheterization on day 45. His right renal artery was not visualized by angiography, and his right kidney was fed by collateral arteries, while vascular echocardiography revealed patency of his right renal artery with severe stenosis. We also confirmed celiac artery occlusion and superior mesenteric artery stenosis to be the same as those observed in previous echocardiography findings. His cardiac function gradually improved. After his C-reactive protein levels returned to normal, 1 mg/kg per day of prednisolone was administered for 1 month, after which the dose was tapered every other 2 weeks. We observed him for 13 months after the termination of lipo-PGE1. The inflammatory findings remained negative and the diameters of abdominal aortic vessels were stable.", "summary": "A Japanese 11-month-old baby boy presented with Takayasu’s arteritis and heart failure, possibly due to afterload mismatch caused by high blood pressure. Computed tomography was performed and revealed thoracic and abdominal aortic aneurysms. It also revealed severe celiac artery stenosis and bilateral renal artery stenosis. Prednisolone was initiated as first-line therapy. The fever resolved, and C-reactive protein levels returned to normal. Although his general condition improved, deterioration of vascular lesions was evident. Celiac artery occlusion, severe right renal artery stenosis, and new superior mesenteric artery stenosis were observed. We decided to use a continuous infusion of lipo-prostaglandin E1 for prevention of branch stenosis of his abdominal aorta. The progression of vascular stenosis was stopped and our patient’s cardiac function gradually improved.", "subclaim_evaluations": [ { "subclaim": "The patient is an 11-month-old Japanese boy.", "support_label": "supported", "is_refined": false }, { "subclaim": "The patient was diagnosed with Takayasu’s arteritis.", "support_label": "supported", "is_refined": false }, { "subclaim": "The patient had heart failure.", "support_label": "supported", "is_refined": false }, { "subclaim": "Computed tomography revealed thoracic aortic aneurysms.", "support_label": "supported", "is_refined": false }, { "subclaim": "Computed tomography revealed abdominal aortic aneurysms.", "support_label": "supported", "is_refined": false }, { "subclaim": "Computed tomography showed severe celiac artery stenosis.", "support_label": "supported", "is_refined": false }, { "subclaim": "Computed tomography showed bilateral renal artery stenosis.", "support_label": "supported", "is_refined": false }, { "subclaim": "Prednisolone was initiated as first-line therapy.", "support_label": "supported", "is_refined": false }, { "subclaim": "The fever resolved after treatment.", "support_label": "supported", "is_refined": false }, { "subclaim": "C-reactive protein levels returned to normal.", "support_label": "supported", "is_refined": false }, { "subclaim": "Deterioration of vascular lesions was evident.", "support_label": "supported", "is_refined": false }, { "subclaim": "Celiac artery occlusion was observed.", "support_label": "supported", "is_refined": false }, { "subclaim": "Severe right renal artery stenosis was observed.", "support_label": "supported", "is_refined": false }, { "subclaim": "New superior mesenteric artery stenosis was observed.", "support_label": "supported", "is_refined": false }, { "subclaim": "A continuous infusion of lipo-prostaglandin E1 was used.", "support_label": "supported", "is_refined": false }, { "subclaim": "The progression of vascular stenosis was stopped.", "support_label": "supported", "is_refined": false }, { "subclaim": "The patient’s cardiac function gradually improved.", "support_label": "supported", "is_refined": false } ] }, { "id": "multiclinsum_test_777_en.txt", "fulltext": "A 58-year-old man underwent laparoscopic radical resection of sigmoid carcinoma and ileostomy in the local hospital in June 2017. After the operation, he underwent intermittent chemotherapy six times. His physical condition recovered, and the re-examination showed no tumor recurrence. The patient was expected to undergo ileostomy takedown in the local hospital in June 2018 and April 2019, respectively, but the operation was not performed because of the COA, which was found by colonoscopy. The patient was admitted to the Department of Gastroenterology, Union Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, Hubei Province, China in May 2019. To address the difficult and complicated post-surgery problems of this cancer patient, the medical team conducted a comprehensive and careful related examination and disease evaluation. The abdominal enhanced computed tomography (CT) showed postoperative changes of sigmoid carcinoma. The intestinal lumen above the anastomotic stoma was narrow and adhered to the anterior sacral fascia. The stoma was unobstructed after the right lower abdominal fistulation . Further barium enema examination suggested that the anastomotic stoma in rectum is completely closed and separated . Blind ends were present on both sides of the sigmoid colon and the rectum, and the bilateral blind ends were approximately 3.0 cm apart. The laboratory examination of the patients showed that there was no obvious abnormality in the general hemogram and no significant change in the level of tumor markers. Physical examination showed no obvious discomfort.\nDespite the presence of COA with anastomotic separation, the examination results indicated that the blind end of the anastomotic site grew well. No obvious defect was found in the surrounding tissue. At the same time, the additional surgical operation would bring more trauma. Therefore, after speaking with the patient and his family, we planned to perform endoscopic operation on the patient to treat his disease. If endoscopic surgery cannot solve the problem, then surgery can be performed immediately or postponed as an alternative.\nAfter the improvement of the preoperative examination, along with adequate preoperative communication and informed consent of patients, endoscopic surgery was proposed. In endoscopic surgery , we first observed the two blind ends of the anastomotic stoma through colonoscopy. On the one hand, the COA can be seen at about 8 cm through the anus side of colonoscopy. The closure line showed a fine line scar, and the intestinal wall at the blind end was soft. On the other hand, the colonoscope entered through the ileostomy side to reach the rectal segment. The front of the blind end of the bowel was found to also be truncated and closed with a white linear scar, and a titanium clip was placed at the proximal blind end. The intestinal wall of this blind end was also soft when touched. Second, the distance between the blind ends of both sides of the intestine was 3–4 cm, as measured by fluoroscopy at different positions. Subsequently, the colonoscope re-entered through the anal side. The hook knife (KDL-620LR; Olympus Optical) was used to slowly cut through the scar tissue layer by layer in the center of the blind end of the intestinal canal, and the yellow adipose tissue became visible. The direction of incision was determined to be parallel to the direction of the titanium clip at the proximal blind end, as shown by repeated fluoroscopic observation. The adipose tissue was carefully cut open, and the proximal intestinal muscular layer was still not visible after 4 cm of advance. Third, EUS-FNA (19 Ga, 1.10 mm; Boston Scientific) puncture needle was used to puncture along the direction of the titanium clip under fluoroscopy, and a small amount of contrast agent was injected to observe the flow direction and the visualization of the intestinal canal. The intestine was visualized after the needle touched the titanium clip, and a yellow zebra guide wire was placed after the needle entered the proximal intestine. Finally, colonoscopy was performed through one side of ileostomy to confirm that the guide wire was located in the proximal intestine tube. The dilation tube and balloon (M00558430; Boston Scientific) were inserted over the guide wire, and the incised bowel was gradually dilated to 12 mm under fluoroscopy. Subsequently, a 60 mm * 20 mm self-expandable full-coated metal stent (Cook Medical, Bloomington, IN, USA) was placed over the guide wire to bridge both sides of the intestine, thereby achieving the repair of anastomotic closure with separation through the endoscopic operation. After completion of the operation, the patency of the stent was checked, no bleeding was found on the wound surface, and the anal canal was retained. Compared with the “drastic” surgical operation, this endoscopic surgery solved the intractable problem of COA with anastomotic separation with a more delicate and subtle operation and with minimal trauma. Endoscopic stent removal was performed on the patient 10 days later. The continuity of the bowel was observed intraoperatively, and an anal tube was placed in the proximal part of the anastomosis to observe the postoperative recovery.\nOne month later, stenosis was observed at the original anastomotic recanalization site during endoscopic examination, and scar-like hyperplasia was observed in the surrounding tissues. We successfully leaped over the narrow segment through inserting a new self-expandable full-coated metal stent of the same specification, and the stent expanded smoothly . After 1 week, the patient underwent stent removal and came to our hospital for follow-up and reexamination for several times after discharge. The anastomotic stenosis of the patient was gradually relieved. At 1 year after the endoscopic recanalization procedure for COA with anastomotic separation, the patient came to our hospital in June 2020 for ileostomy takedown. No related complications occurred during and after the operation. No obvious abnormality was found in the relevant post-operation laboratory and imaging examinations.\nThe follow-up situation at 3 months after discharge was as follows. The patient returned to a normal diet from a fluid diet and achieved normal exhaust and defecation. The results of colonoscopy showed that the anastomotic stoma healed well, and no obvious stenosis was found. At the same time, biopsy and pathological examination were carried out on the new tissue of the original anastomotic closure with anastomotic separation. The pathological results indicated that this site was normal intestinal mucosal tissue . Further endoscopic ultrasonography also confirmed the growth of normal intestinal mucosal tissues at the original anastomotic recanalization site .", "summary": "In this article, we present a case of endoscopic treatment of anastomotic closure and separation after radical resection for sigmoid carcinoma. After imaging examination and endoscopic evaluation, we found that the patient had a COA accompanied by a 3-4 cm anastomotic separation. With the aid of fluoroscopy, we attempted to use the titanium clip marker as a guide to perform an endoscopic incision and successfully achieved recanalization. We used a self-expanding covered metal stent to bridge the intestinal canal to resolve the anastomotic separation. Finally, the patient underwent ileostomy takedown, and the postoperative recovery was smooth. The follow-up evaluation results showed that the anastomotic stoma was unobstructed.", "subclaim_evaluations": [ { "subclaim": "The case involves endoscopic treatment of anastomotic closure and separation after radical resection for sigmoid carcinoma.", "support_label": "supported", "is_refined": false }, { "subclaim": "The patient had a COA.", "support_label": "supported", "is_refined": false }, { "subclaim": "The patient had a 3-4 cm anastomotic separation.", "support_label": "supported", "is_refined": false }, { "subclaim": "Fluoroscopy was used during the procedure.", "support_label": "supported", "is_refined": false }, { "subclaim": "A titanium clip marker was used as a guide.", "support_label": "supported", "is_refined": false }, { "subclaim": "An endoscopic incision was performed.", "support_label": "supported", "is_refined": false }, { "subclaim": "Recanalization was achieved.", "support_label": "supported", "is_refined": false }, { "subclaim": "A self-expanding covered metal stent was used to bridge the intestinal canal.", "support_label": "supported", "is_refined": false }, { "subclaim": "The patient underwent ileostomy takedown.", "support_label": "supported", "is_refined": false }, { "subclaim": "The postoperative recovery was smooth.", "support_label": "supported", "is_refined": false }, { "subclaim": "Follow-up evaluation showed the anastomotic stoma was unobstructed.", "support_label": "supported", "is_refined": false } ] }, { "id": "multiclinsum_test_807_en.txt", "fulltext": "A 75-year-old woman with a 1-week history of diplopia was referred to the ophthalmology clinic from the medical ward, where she was being treated for atypical pneumonia. She had been unwell for a few months with loss of appetite and weight. Sputum acid-fast bacillus smear and culture tests for tuberculosis were negative. There were no specific symptoms or signs suggestive of giant cell arteritis (GCA) but the erythrocyte sedimentation rate (ESR) was 98 mm/hour and the C-reactive protein was more than 139 mg/dl, which prompted the physicians to arrange a temporal artery biopsy. This was later reported as normal.\nOphthalmic examination showed corrected visual acuity of 6/6 bilaterally. There was subtle localized episcleral injection near the right lateral rectus muscle insertion. The posterior segment revealed a normal optic disc and macula bilaterally. Ocular motility revealed an abduction deficit in the right eye .\nComputed tomography (CT) scanning of the head and orbits revealed a mass in the belly of the right lateral rectus suggestive of a metastatic lesion . Subsequent CT and magnetic resonance imaging (MRI) of the thorax and abdomen showed multiple secondary metastatic lesions in the lung and enlargement of retroperitoneal lymph nodes. The patient underwent an endoscopic retrograde cholangiopancreatography and the cytology of the brushings was highly suggestive of anaplasia. Pancreatic carcinoma was suspected but abdominal CT scanning and ultrasonic studies revealed no evidence. The patient later developed a supraclavicular lymph node mass, bilateral axillary lymphadenopathy and enlarged spleen. A supraclavicular lymph node biopsy was inconclusive. The suspected diagnosis of pancreatic cancer remained unconfirmed. The general condition of the patient had deteriorated, precluding further invasive investigations such as orbital biopsy. The patient died 4 months after her initial diagnosis of orbital metastasis. Autopsy was not performed on the body.", "summary": "We present the case of a 75-year-old woman who was generally unwell, developed acute diplopia and was found to have a right abduction deficit in a quiet eye with no gross orbital signs and symptoms. A computed tomography scan of the head and orbits revealed a metastatic mass in the right lateral rectus muscle. Systemic evaluation confirmed widespread thoracic and abdominal metastases from an occult systemic malignancy. Lateral rectus metastasis from an occult systemic malignancy was masquerading as abducens palsy.", "subclaim_evaluations": [ { "subclaim": "The patient was a 75-year-old woman.", "support_label": "supported", "is_refined": false }, { "subclaim": "The patient was generally unwell.", "support_label": "supported", "is_refined": false }, { "subclaim": "The patient developed acute diplopia.", "support_label": "supported", "is_refined": false }, { "subclaim": "The patient had a right abduction deficit in a quiet eye.", "support_label": "supported", "is_refined": false }, { "subclaim": "There were no gross orbital signs and symptoms.", "support_label": "not_supported", "original_label": "not_supported", "reasoning_audit": "No explicit tags provided.", "is_refined": true }, { "subclaim": "A computed tomography scan of the head and orbits was performed.", "support_label": "supported", "is_refined": false }, { "subclaim": "The scan revealed a metastatic mass in the right lateral rectus muscle.", "support_label": "supported", "is_refined": false }, { "subclaim": "Systemic evaluation confirmed widespread thoracic and abdominal metastases.", "support_label": "supported", "is_refined": false }, { "subclaim": "The metastases were from an occult systemic malignancy.", "support_label": "supported", "is_refined": false }, { "subclaim": "Lateral rectus metastasis was masquerading as abducens palsy.", "support_label": "supported", "is_refined": false } ] }, { "id": "multiclinsum_test_1363_en.txt", "fulltext": "A 77-year-old African American woman with a medical history of hypertension presented with a systolic blood pressure of 200 mmHg. There was no significant family or social history. A renal ultrasound showed a 12 × 9 × 7.5 cm mass medial to the left kidney. A follow-up computed tomography (CT) scan showed an enhancing 9 × 6 cm mass anterior and medial to the left kidney. Laboratory studies revealed a normal dexamethasone suppression test and an elevated androstenedione level of 182 ng/dl. Given these results, an androgen-producing adrenal tumor was suspected. The differential diagnosis also included pheochromocytoma, lymphoma, and mesenteric gastrointestinal stromal tumor. The patient underwent robotic-assisted left adrenalectomy. The intraoperative finding of “focal invasion” into the renal parenchyma raised the possibility of adrenal cortical carcinoma; therefore, an additional left upper pole partial nephrectomy was performed. The specimen received was an 11 × 7.2 × 6.8 cm adrenal mass with attached portion of kidney. The mass was golden yellow, well circumscribed, and grossly adherent to the kidney. Histologic evaluation revealed an adrenal cortical adenoma without any features of malignancy, with a Weiss score of 0 . The adjacent adrenal parenchyma shared an incomplete capsule with the kidney and was in direct contact with the renal cortex, establishing the diagnosis of fusion between the two organs . The postoperative course was uneventful.", "summary": "Our patient is a 77-year-old African American female who presented with a systolic blood pressure of 200 mmHg. Computed tomography showed an enhancing 9 × 6 cm mass anterior and medial to the left kidney. The patient underwent a left adrenalectomy with partial nephrectomy. Gross and histologic examinations revealed an adrenal cortical adenoma and renal-adrenal fusion.", "subclaim_evaluations": [ { "subclaim": "The patient is a 77-year-old African American female.", "support_label": "supported", "is_refined": false }, { "subclaim": "The patient had a systolic blood pressure of 200 mmHg.", "support_label": "supported", "is_refined": false }, { "subclaim": "Computed tomography showed an enhancing 9 × 6 cm mass.", "support_label": "supported", "is_refined": false }, { "subclaim": "The mass was anterior and medial to the left kidney.", "support_label": "supported", "is_refined": false }, { "subclaim": "The patient underwent a left adrenalectomy.", "support_label": "supported", "is_refined": false }, { "subclaim": "The patient underwent a partial nephrectomy.", "support_label": "supported", "is_refined": false }, { "subclaim": "Gross examination revealed an adrenal cortical adenoma.", "support_label": "supported", "is_refined": false }, { "subclaim": "Histologic examination revealed an adrenal cortical adenoma.", "support_label": "supported", "is_refined": false }, { "subclaim": "Gross examination revealed renal-adrenal fusion.", "support_label": "supported", "is_refined": false }, { "subclaim": "Histologic examination revealed renal-adrenal fusion.", "support_label": "supported", "is_refined": false } ] }, { "id": "multiclinsum_test_3120_en.txt", "fulltext": "36-year-old man with no medical history who was admitted to the intensive care unit with a presumptive diagnosis of malaria on 7/12/2021. His medical history included a stay in Nigeria from January to October 2021; he did not receive malaria prophylaxis. He arrived in the country on 28/11/21 from Germany. He began with continuous fever, sweating, chills and myo-artralgia of 1 week evolution, oligoanuria, copuria and abdominal pain were added. He was admitted to the intensive care unit lucid, tachycardic and tachypneic, with skin and mucous jaundice and a decrease in diuretic rhythm. He evolved with arterial hypertension and a requirement for nitroglycerine. A thick drop of peripheral blood was performed that evidenced PF, with parasitemia greater than 20%. A transfusion of blood was performed (volume 3.4 liters) and intravenous artesunate 400 mg on the 1st day, then 200 mg per day, for 7 days. In clinical analyses, an acute renal lesion and hyperbilirubinemia with platelopenia were detected. He evolved oligoanuric and confused, with a Glasgow score of 14/15 points. The initiation of veno-venous continuous haemodiafiltration (HDFVVC) was decided. After 24 hours, due to a sudden increase in bilirubinemia and a deepening of his encephalopathy, plasma filtration was performed coupled with adsorption (CPFA). Subsequently, high-exchange plasmaferesis was performed to control the liver failure. An improvement in the neurological state and a significant decrease in the serum bilirubin and analyte levels were detected.\n\nLucid, but with persistently high uremia and creatinine levels, he continued with continuous renal replacement techniques until the eighth day of admission. The evolution was favorable with improvement of the organ failures and on the 20th day of admission he was discharged. The case described presented MG according to WHO definition. No adverse events related to the procedures were detected.\n", "summary": "A case of a 36-year-old man with a diagnosis of severe malaria according to the criteria of the World Health Organization (WHO) who began with treatment with intravenous artesunate and a torpid evolution, a sudden increase in bilirrubinemia with encephalopathy, parameters of acute renal injury and acute pulmonary edema, performed sequential extracorporeal treatment, plasma filtration coupled to adsorption, high-exchange plasmapheresis and continuous hemodiafiltration with a favorable evolution is described.\n", "subclaim_evaluations": [ { "subclaim": "The patient was a 36-year-old man.", "support_label": "supported", "is_refined": false }, { "subclaim": "The patient had a diagnosis of severe malaria according to WHO criteria.", "support_label": "supported", "is_refined": false }, { "subclaim": "The patient received intravenous artesunate as treatment.", "support_label": "supported", "is_refined": false }, { "subclaim": "The patient had a torpid evolution.", "support_label": "not_supported", "original_label": "not_supported", "reasoning_audit": "No explicit tags provided.", "is_refined": true }, { "subclaim": "The patient had a sudden increase in bilirrubinemia.", "support_label": "supported", "is_refined": false }, { "subclaim": "The patient developed encephalopathy.", "support_label": "supported", "is_refined": false }, { "subclaim": "The patient had parameters of acute renal injury.", "support_label": "supported", "is_refined": false }, { "subclaim": "The patient had acute pulmonary edema.", "support_label": "not_supported", "original_label": "not_supported", "reasoning_audit": "No explicit tags provided.", "is_refined": true }, { "subclaim": "The patient received sequential extracorporeal treatment.", "support_label": "supported", "is_refined": false }, { "subclaim": "The patient received plasma filtration coupled to adsorption.", "support_label": "supported", "is_refined": false }, { "subclaim": "The patient received high-exchange plasmapheresis.", "support_label": "supported", "is_refined": false }, { "subclaim": "The patient received continuous hemodiafiltration.", "support_label": "supported", "is_refined": false }, { "subclaim": "The patient had a favorable evolution.", "support_label": "supported", "is_refined": false } ] }, { "id": "multiclinsum_test_1999_en.txt", "fulltext": "A 15-year-old male presented with the sudden onset of a hemiparesis (i.e., left upper limb 4/5 and left lower limb 4/5). The laboratory work up was negative for any coagulation abnormalities; normal international normalized ratio, prothrombin time, activated partial thrombin time, and bleeding/clotting times. The brain MRI was normal, thus largely ruling out a stroke. However, the cervical MR showed a dorsolateral left-sided epidural hematoma extending from C7 to D1 causing severe cord compression. The lesion was hyperintense on T1, hyperintense with a hypointense band on T2 studies, but did not enhance with contrast [- and ]. These findings were diagnostic for a SSEH. The patient underwent an emergent C7-D1 laminectomy for excision of the SSEH. Postoperatively, the patient regained normal function.", "summary": "A 15-year-old male presented with the sudden onset of a hemiparesis which recovered (4/5 weakness). The brain MR was negative, but spinal MRI revealed a dorsolateral extradural lesion extending from C7 to D1. At surgery, this proved to be a hematoma that we readily removed.", "subclaim_evaluations": [ { "subclaim": "The patient is a 15-year-old male.", "support_label": "supported", "is_refined": false }, { "subclaim": "He had a sudden onset of hemiparesis.", "support_label": "supported", "is_refined": false }, { "subclaim": "The hemiparesis recovered.", "support_label": "supported", "is_refined": false }, { "subclaim": "The brain MRI was negative.", "support_label": "supported", "is_refined": false }, { "subclaim": "The spinal MRI showed a dorsolateral extradural lesion.", "support_label": "supported", "is_refined": false }, { "subclaim": "The lesion extended from C7 to D1.", "support_label": "supported", "is_refined": false }, { "subclaim": "The lesion was a hematoma.", "support_label": "supported", "is_refined": false }, { "subclaim": "The hematoma was removed surgically.", "support_label": "supported", "is_refined": false } ] }, { "id": "multiclinsum_test_223_en.txt", "fulltext": "A 64-year-old Asian gentleman was admitted for fever (101.6F), worsening cough and shortness of breath for 10 days. He is a non-smoker and has a remote history of fungal infection of lung over 20 years ago while being a farmer. For the past 3–4 years, he has been taken care in our hospital for persistent and exacerbated asthma, chronic obstructive pulmonary disease (COPD), diabetes, coronary heart disease and congestive heart disease. His home medications for asthma and COPD are albuterol sulfate HFA − 1.25 mg/3 ml, PRN Q4H, Duoneb (a combination of albuterol and Ipratropium Bromide), Budesonid (Pulmicort, cortisone like medicine, NEB 0.5 mg/2 ml) inhalation. During previous asthma exacerbation 13 months ago, methylprednisone injection 40 mg IVP, Q8H and antibiotics Amoxicillin/clavulanic acid were used additionally. During his COPD exacerbation 2 years ago, PrednioSONE TAB—20MG, 40MG PO, daily was also given. In current attack, dexamethasone 10 mg per day, Duoneb and empirical antibiotics azithromycin were initiated in the outpatient setting before admission. The COVID19 nasopharyngeal RT-PCR test performed in doctor's office outside hospital on day 5 of symptom onset was negative.\nOn admission, his BMI was 21.10 kg/m2. His arterial blood gas oxygen was 74 mmHg (normal 75–100) with saturation 96.1% (normal 92–98.5%), and the partial pressure of carbon dioxide pCO2 was 32 mmHg (normal 35–45), pH was 7.48.\nThe laboratory work showed high white cell count up to 22 × 103/ul with predominant neutrophils (neutrophils 79% and 17 × 103/ul, and the eosinophils accounting for 0–3%), moderate anemia (8–10 g/dl), and reactive thrombocytosis (500–650 × 103/ul). Immunoglobulin E was high (875, normal < = 114). D-dimer was slightly elevated (2.73 ug/ml, reference < 0.5), as well as N-terminal prohormone of brain natriuretic peptide (NT-PROBNP 1270 pg/ml, reference 0–900). Lactic acid was high 4.6 nmol/L (0.7–1.9). C-reactive protein was also elevated. Ferritin and procalcitonin were within normal limit. The extensive antigen, antibody and culture workups for common infectious disease pathogens such as tuberculosis, hepatitis, HIV, bacteria (including Streptococcus, Legionella etc.), fungi (including coccidioidomycosis, Cryptococcus etc.) were all negative. There was no autoantibody (antinuclear antibody, anti-neutrophil cytoplasmic antibody) either. The repeated nasopharyngeal tests on day 10, 13 and 14 of symptom onset performed in hospital after initial negative result on day 5 were all negative, and IgG antibody for COVID19 on day 16 was also negative.\nThe chest CT and X-ray showed peripherally based ground-glass opacities and consolidation, in contrast with the more centrally located shadings during asthma acceleration 13 months ago . This is an established imaging manifestation of active COVID-19 infection, but remains nonspecific, as other infections and airspace diseases have a similar appearance. No pulmonary embolism was identified by pulmonary CT.\nHe was precautiously isolated because of the uncertainty for COVID19. He was managed by empirical antibiotics, inhaled corticosteroid and bronchodilator as well as systemic steroids, besides aspirin, diuresis and diabetic medicines. The major medications addressing the lung disease are:\n- Antibiotics: azithromycin (500 mg oral daily, days 5 – 14), ceftriaxone (1 gm, iv, days 9–15), Zosyn (3.375 gm, days 15–19), cefepime (1gm, days 21–31), fluconazole (200 mg, days 22–33), meropenem (1 gm, days 36–40), vancomycin (750–1000 mg, days 36–40).\n- Corticosteroid and bronchodilator inhalation medicines for asthma and COPD: Advair (Flutica-Salmet, which is a steroid and bronchodilator combination, MDI 250-50 MCG/puff, days 11–25), Budesonide (Pulmicort, cortisone like medicine, 0.5 mg × 2 per day inhalation, days 16–50), Duoneb (Ipratr-albut, which is a bronchodilator containing beta adrenergic and anticholinergic medicines, 0.5–3 mg/3 ml, Q4H, days 5–50).\n-Systemic steroid: dexamethasone (10 mg on days 5–10, 6 mg on days 11–37), methylPRED SUC (Solu-MEDROL, 40 mg, days 16–20, 24–33 and 37–50), and Prednisone (10 mg, days 33–37).\nHis disease was stabilized initially . On day 18, his symptoms deteriorated with Sat.O2 dropped from 74 to 54 mmHg. The chest X-ray showed increased bilateral lung opacity . The aforementioned medications including antifungal, antibacterial, bronchodilator, inhaled and systemic steroids were no longer helpful improving symptoms .\nAt this time, bronchoalveolar lavage (BAL) was performed to identify an infectious etiology and open lung wedge biopsy was due to rule out interstitial lung disease.\nThe bronchoalveolar lavage showed some pneumocytes with acinar arrangement showing enlarged nuclei, prominent nucleoli, open chromatin and mild accentuation of chromatin to nuclear membrane in a background of neutrophilic histiocytic inflammation and occasional eosinophils .\nThe left lingula lung wedge biopsy revealed central bronchiole with thickened smooth muscle wall, and mucus plug, findings consistent with known history of asthma. The presence of central squamous metaplasia and peripheral emphysema indicates chronic airway damage and obstruction suggesting COPD from repeated episodes of asthma. On top of these, there is an active airway centered lesion causing 40–50% alveolar collapse, characterized by fibrosing organizing pneumonia with alveolar damage , intraalveolar edematous exudates, fibrosis from intraalveoli extending to interstitial , associated with rare syncytial cells in squamous metaplasia foci and capillary endothelial injury accompanied by mixed inflammation comprising neutrophils, lymphoplasmacytic cells, histiocytes and eosinophils in all the process. Again, similar to cytology, reactive large pneumocytes are seen lining hemorrhagic alveoli, showing prominent nucleoli, open chromatin and nuclear membrane accentuation, suspicious for viral cytopathic effect . Cytomegalovirus, adenovirus and herpes virus infection is excluded by immunohistochemical stains.\nSARS-CoV-2 was detected from both BAL (Quest Laboratory) and lung wedge biopsy (Viral and Rickettsial Disease Laboratory (VRDL), Department of Public Health, California) by RT-PCR. No respiratory syncytial virus (RSV), influenza A or B, parainfluenza virus or adenovirus is identified by PCR (Quest Laboratory). All three laboratories (nasopharyngeal swab RT-PCR performed by Fulgent Genetics, BAL specimen tested by Quest Laboratory, presence of COVID19 in formalin fixed paraffin-embedded lung wedge biopsy tissue verified by VRDL) use the same primer sets unique to SARS-CoV-2 as designed by Center for disease control and prevention (CDC), US. COVID19 pneumonia is confirmed. The repeated nasopharyngeal RT-PCR tests were positive on day 40 and day 49 of disease.\nAfter the diagnosis of COVID19 pneumonia, patient was treated with Remdesivir (200 mg, day 41–45) and COVID19 convalescent plasma (1 unit, on day 44) besides continuous corticosteroid, bronchodilator and supportive management. The granulocytosis subsided to a nadir of 12 K/ul following treatment. The lung opacity started to dissolve a bit slowly but his hypoxemia persisted which still needed ventilation. Gram negative bacteria was isolated from central catheter on day 50. The infected central line was immediately replaced and patient was treated with antibiotics meropenem, transferred to another hospital for continuous care. Patient unfortunately succumbed to septic complications after two months of disease onset.", "summary": "A 64-year-old male with history of pulmonary fungal infection, asthma and chronic pulmonary obstructive disease (COPD), diabetes, coronary artery disease presented with shortness of breath, fever and chest image of ground opacity, reticular interstitial thickening, highly suspicious for COVID19. However, nasopharyngeal swab tests were discordantly negative for four times in two weeks, and IgG antibody for COVID19 was also negative. However, serum IgE level was elevated. No other pathogens are identified. His symptoms deteriorated despite corticosteroid, antibiotics and bronchodilator treatment. Bronchoalveolar lavage (BAL) and open lung wedge biopsy were performed for etiology diagnosis. They demonstrated COVID19 viral RNA positive fibrosing organizing pneumonia with respiratory tract damage characterized by suspicious viral cytopathic effect, mixed neutrophilic, lymphoplasmacytic, histiocytic and eosinophilic inflammation and fibrosis besides expected asthma and COPD change. One week later, repeated COVID19 nasopharyngeal tests on day 40 and day 49 became positive.", "subclaim_evaluations": [ { "subclaim": "The patient is a 64-year-old male.", "support_label": "supported", "is_refined": false }, { "subclaim": "The patient has a history of pulmonary fungal infection.", "support_label": "supported", "is_refined": false }, { "subclaim": "The patient has asthma.", "support_label": "supported", "is_refined": false }, { "subclaim": "The patient has chronic pulmonary obstructive disease (COPD).", "support_label": "supported", "is_refined": false }, { "subclaim": "The patient has diabetes.", "support_label": "supported", "is_refined": false }, { "subclaim": "The patient has coronary artery disease.", "support_label": "supported", "is_refined": false }, { "subclaim": "The patient presented with shortness of breath.", "support_label": "supported", "is_refined": false }, { "subclaim": "The patient presented with fever.", "support_label": "supported", "is_refined": false }, { "subclaim": "The chest image showed ground opacity.", "support_label": "supported", "is_refined": false }, { "subclaim": "The chest image showed reticular interstitial thickening.", "support_label": "not_supported", "original_label": "not_supported", "reasoning_audit": "No explicit tags provided.", "is_refined": true }, { "subclaim": "The chest image was highly suspicious for COVID19.", "support_label": "supported", "is_refined": false }, { "subclaim": "Nasopharyngeal swab tests were negative four times over two weeks.", "support_label": "supported", "is_refined": false }, { "subclaim": "Serum IgG antibody for COVID19 was negative.", "support_label": "supported", "is_refined": false }, { "subclaim": "Serum IgE level was elevated.", "support_label": "supported", "is_refined": false }, { "subclaim": "No other pathogens were identified.", "support_label": "supported", "is_refined": false }, { "subclaim": "Symptoms deteriorated despite corticosteroid treatment.", "support_label": "supported", "is_refined": false }, { "subclaim": "Symptoms deteriorated despite antibiotic treatment.", "support_label": "supported", "is_refined": false }, { "subclaim": "Symptoms deteriorated despite bronchodilator treatment.", "support_label": "supported", "is_refined": false }, { "subclaim": "Bronchoalveolar lavage (BAL) was performed.", "support_label": "supported", "is_refined": false }, { "subclaim": "Open lung wedge biopsy was performed.", "support_label": "supported", "is_refined": false }, { "subclaim": "BAL and open lung wedge biopsy demonstrated fibrosing organizing pneumonia.", "support_label": "supported", "is_refined": false }, { "subclaim": "BAL and open lung wedge biopsy showed respiratory tract damage.", "support_label": "supported", "is_refined": false }, { "subclaim": "BAL and open lung wedge biopsy showed suspicious viral cytopathic effect.", "support_label": "supported", "is_refined": false }, { "subclaim": "BAL and open lung wedge biopsy showed mixed neutrophilic, lymphoplasmacytic, histiocytic, and eosinophilic inflammation.", "support_label": "supported", "is_refined": false }, { "subclaim": "BAL and open lung wedge biopsy showed fibrosis.", "support_label": "supported", "is_refined": false }, { "subclaim": "The patient had expected asthma and COPD changes.", "support_label": "supported", "is_refined": false }, { "subclaim": "Repeated nasopharyngeal tests on day 40 and day 49 became positive.", "support_label": "supported", "is_refined": false } ] }, { "id": "multiclinsum_test_2275_en.txt", "fulltext": "A 68-year-old Caucasian man was referred to our out-patients clinic following the incidental discovery of a 6 × 8 cm distended iliac vessel whilst having an ultrasound for surveillance of liver cirrhosis. His clinical history revealed a progressive history of right flank pain, worsening right leg claudication and a persistently cold sensation in his right foot. He also complained of progressive breathlessness on exertion, clinically suggestive of deteriorating CCF. There was no history of trauma or previous surgery. Ankle-brachial pressure measurements revealed a reduced index of 0.76 on the right, and a normal index of 1.35 on the left with corresponding toe pressures of 55 mmHg and 143 mmHg respectively. A contrast enhanced computed tomography (CT) scan showed an isolated right common iliac artery (CIA) to right common iliac vein AVF . His aorta was normal in caliber, measuring 19 mm at the aortic bifurcation. The aneurysmal segment began immediately distal to the aortic bifurcation at the origin of the right CIA, with no normal segment of CIA evident. The aneurysm measured 9.4 cm in maximal diameter and extended to within 17 mm of the right iliac bifurcation. It was impossible to differentiate the arterial wall from the venous wall in the aneurysmal segment on either ultrasound or CT scans. His inferior vena cava (IVC) was grossly distended with a uniform diameter of 36 mm in its full course.\nPre-operative discussions focused on finding an endovascular strategy to solve the problem. As no normal caliber proximal right CIA existed, an isolated iliac covered stent was impossible as no proximal sealing zone existed. This required sealing a proximal stent in his aorta. Bifurcated endografts have been used to seal ilio-iliac fistulae previously . The aortic bifurcation diameter was 19 mm in this case and although some devices have reported success negotiating smaller aortic bifurcations , we felt an aorto-bi-iliac graft would be in danger of being compressed at the bifurcation with a high risk of occlusion. As a result, a hybrid approach with deployment of an aorto-uni-iliac (AUI) device followed by a femoro-femoral bypass was planned. Our patient was operated upon in our endovascular suite (Siemens) under spinal anesthesia. Both common femoral arteries (CFA) were controlled and cannulated with 6Fr sheaths (Johnston & Johnston). His aorta was cannulated with a 0.035 wire Bentson wire (Cook Medical, Bloomington, IN, USA) via each CFA with the assistance of an angled catheter (Kumpe, Cook Medical). A diagnostic flush pigtail catheter was placed in his aorta via the contralateral limb. A stiff 0.035 Amplatz wire (Amplatz Super Stiff, Boston Scientific) was exchanged as access to the ipsilateral limb. Following an angiogram to confirm renal anatomy, an aorto-uni-iliac device (Zenith Renu, Cook Medical) was deployed from immediately below his renal arteries to his mid right external iliac artery, thus occluding his right internal iliac artery. A 14 × 10 mm Amplatzer occlusion device (AGA Medical Corp, MN, USA) was deployed via the contralateral limb to his proximal left CIA. A completion angiogram confirmed exclusion of the ilio-iliac AVF. A right to left femoro-femoral bypass with 8 mm polytetrafluoroethylene (PTFE) was performed to re-establish flow to his left leg as well as providing left internal iliac perfusion.\nOn the first postoperative day, the mass was no longer pulsatile and the machinery-like murmur in the right iliac fossa was absent. A CT scan on postoperative day two confirmed a patent AUI endovascular graft and patent femoro-femoral bypass, as well as confirming exclusion of contrast from the right iliocaval system . His right foot no longer felt cool and the postoperative ankle brachial index (ABI) confirmed an index of 1.05 on the right and 0.95 on the left, with corresponding toe pressures of 119 mmHg and 117 mmHg respectively. He was discharged after seven days without complication. At a clinic one month later, his claudication had resolved completely and he no longer had symptoms suggestive of CCF. A duplex ultrasound confirmed exclusion of arterial flow from the iliocaval vessels.", "summary": "We report a case of a spontaneous ilio-iliac arteriovenous fistula in a 68-year-old Caucasian man detected following presentation with unilateral claudication and congestive cardiac failure. Following computed tomography evaluation, the fistula was successfully treated with a combined endovascular (aorto-uni-iliac device) and open (femoro-femoral crossover) approach.", "subclaim_evaluations": [ { "subclaim": "The patient was a 68-year-old man.", "support_label": "supported", "is_refined": false }, { "subclaim": "The patient was Caucasian.", "support_label": "supported", "is_refined": false }, { "subclaim": "The patient had a spontaneous ilio-iliac arteriovenous fistula.", "support_label": "not_supported", "original_label": "not_supported", "reasoning_audit": "No explicit tags provided.", "is_refined": true }, { "subclaim": "The fistula was detected following presentation with unilateral claudication.", "support_label": "supported", "is_refined": false }, { "subclaim": "The fistula was detected following presentation with congestive cardiac failure.", "support_label": "not_supported", "original_label": "not_supported", "reasoning_audit": "No explicit tags provided.", "is_refined": true }, { "subclaim": "Computed tomography was used to evaluate the fistula.", "support_label": "supported", "is_refined": false }, { "subclaim": "The fistula was treated with a combined endovascular and open approach.", "support_label": "supported", "is_refined": false }, { "subclaim": "The endovascular treatment used an aorto-uni-iliac device.", "support_label": "supported", "is_refined": false }, { "subclaim": "The open treatment used a femoro-femoral crossover.", "support_label": "supported", "is_refined": false }, { "subclaim": "The treatment was successful.", "support_label": "supported", "is_refined": false } ] }, { "id": "multiclinsum_test_1650_en.txt", "fulltext": "A 37-year-old woman presented at the emergency department (ED) with exertional dyspnoea New York Class Association (NYHA) functional classes II and III, syncope, and new onset of T-wave inversions in the ECG . She presented in a clinically stable condition with a blood pressure of 130/80 mmHg, a pulse of 90/min, and an oxygen saturation of 96%. The clinical examination was unremarkable. Her only significant medical history was Crohn’s disease, which had been well controlled with adalimumab for 3 years. Computed tomography (CT) ruled out a pulmonary embolism and parenchymal lung disease . The transthoracic echocardiographic (TTE) findings were consistent with a cor pulmonale without signs of an intracardiac shunt or a left ventricular (LV) pathology (see , ). Right heart catheterization proved a precapillary PH with a negative vasoreactivity testing (mPAP 33 mmHg, pulmonary vascular resistance 4.8 WU, pulmonary arterial wedge pressure 7 mmHg, and central venous pressure 4 mmHg). Perfusion–ventilation scintigraphy displays small peripheral perfusion defects .\nThe presence of peripheral perfusion defects in scintigraphy was initially interpreted as possible chronic thromboembolic PH, and anticoagulation with heparin was started. However, the findings were later interpreted as in context of PH Group 1. Therefore, a PH specific therapy with macitentan and tadalafil was initiated under the continuation of heparin. The short-term course was then complicated by a heparin-induced thrombocytopenia (HIT) that was confirmed by a positive antibody test (HIT antibodies: IgG 6.96 U/mL) with otherwise normal coagulation parameters. Shortly thereafter, an episode of haematemesis occurred, and gastroscopy revealed a gastric adenocarcinoma. An escape chemotherapy regimen was launched before completion of tumour staging. Staging CT revealed subpleural nodular ground glass opacities with ‘feeding vessel sign’ compatible with PH but no metastatic spread of gastric cancer . Consequently, oncologic treatment was changed to a neoadjuvant chemotherapy and subsequent gastrectomy. The patient’s symptoms improved shortly after the first administration of chemotherapy and resolved completely within 2 months. Retrospectively, we considered a pulmonary tumour thrombotic microangiopathy (PTTM) the most probable cause of PH. Follow-up after successful oncologic treatment and cumulative 10 months of specific PH medication showed an excellent clinical response; hence, specific PH therapy was ceased (see , ; ). A subsequently performed RHC confirmed complete remission of PH at rest (mPAP 17 mmHg, pulmonary vascular resistance 1.6 WU, pulmonary arterial wedge pressure 9 mmHg, and central venous pressure 5 mmHg).", "summary": "A 37-year-old woman presented with exertional dyspnoea and syncope. The transthoracic echocardiographic findings were consistent with a cor pulmonale. Right heart catheterization (RHC) proved a precapillary PH. Specific PH therapy with macitentan and tadalafil was initiated. Shortly thereafter, a gastric carcinoma was diagnosed, and oncologic treatment with neoadjuvant chemotherapy and subsequent gastrectomy was promptly initiated. Retrospectively, we considered a pulmonary tumour thrombotic microangiopathy the most probable cause of PH. Follow-up after successful oncologic treatment and cumulative 10 months of specific PH medication showed an excellent clinical response with complete remission of PH confirmed by RHC at rest.", "subclaim_evaluations": [ { "subclaim": "The patient is a 37-year-old woman.", "support_label": "supported", "is_refined": false }, { "subclaim": "She presented with exertional dyspnoea.", "support_label": "supported", "is_refined": false }, { "subclaim": "She presented with syncope.", "support_label": "supported", "is_refined": false }, { "subclaim": "Transthoracic echocardiographic findings were consistent with cor pulmonale.", "support_label": "supported", "is_refined": false }, { "subclaim": "Right heart catheterization proved a precapillary pulmonary hypertension.", "support_label": "supported", "is_refined": false }, { "subclaim": "Specific pulmonary hypertension therapy with macitentan was initiated.", "support_label": "supported", "is_refined": false }, { "subclaim": "Specific pulmonary hypertension therapy with tadalafil was initiated.", "support_label": "supported", "is_refined": false }, { "subclaim": "A gastric carcinoma was diagnosed.", "support_label": "supported", "is_refined": false }, { "subclaim": "Oncologic treatment with neoadjuvant chemotherapy was initiated.", "support_label": "supported", "is_refined": false }, { "subclaim": "Oncologic treatment with gastrectomy was initiated.", "support_label": "supported", "is_refined": false }, { "subclaim": "Pulmonary tumour thrombotic microangiopathy was considered the most probable cause of pulmonary hypertension.", "support_label": "supported", "is_refined": false }, { "subclaim": "Follow-up after 10 months of specific pulmonary hypertension medication showed an excellent clinical response.", "support_label": "supported", "is_refined": false }, { "subclaim": "Right heart catheterization at rest confirmed complete remission of pulmonary hypertension.", "support_label": "supported", "is_refined": false } ] }, { "id": "multiclinsum_test_2585_en.txt", "fulltext": "A 25-year-old woman was admitted to our emergency department after a fall from a chair onto her outstretched left hand. Due to mild alcohol consumption, communication with her was unsatisfactory. She complained of pain and inability to use her elbow, while no other injuries were found. She had a clear medical history, with no comorbidities, except smoking. Physical examination revealed swelling and “dinner fork” deformity of her left wrist, tenderness over her left elbow without any bruises or open wounds, while no obvious neurovascular injury was recognised. Frontal and lateral plain roentgenograms of her left forearm revealed a type-1 Bado Monteggia lesion accompanied with an ipsilateral type 1 Frykman distal radius fracture (Colles’ fracture) with dorsal comminution (, ). Fortunately, no other fractures were found around her elbow, such as coronoid process or radial head fracture. Presence of such associated injuries compromises the final outcome. The patient was operated on within 8 h after admission, under general anesthesia and tourniquet. At the operating room, the neurological examination was repeated, but no neurological disorder was indicated. The ulna was anatomically reduced and fixed through the classical lateral approach between flexor and extensor carpi ulnaris. Osteosynthesis was performed using a dynamic compression plate (3.5 mm limited contact dynamic compression plate [LC-DCP]). Intraoperative, fluoroscopy showed a spontaneous reduction of the anteriorly dislocated radial head after the ulna’s fixation. Subsequently, through a Henry approach, the distal radius fracture was reduced and fixed with a 3.5 mm T-shaped buttress locking plate . Intraoperatively, after the fixation of both fractures, the elbow was found to be stable in all directions with a full range of motion of wrist, elbow, and forearm. The post-operative course was uneventful, and our patient was discharged 2 days after surgery with a dorsal plaster splint. The cast was removed 2 weeks after surgery, and then gradually the mobilization began. The range of wrist (arc: 108°) and elbow (arc: 0—°) motion, as well as the supination and pronation (overall arc: 175°) of the forearm recovered completely 2.5 months postoperatively . Roentgenograms and clinical evaluation showed completed bone union of both fractures’ sides 3.5 months after surgery (, ). The patient returned to her daily routine within 4 months following injury. At last follow-up, 6 months postoperatively, the Broberg and Morrey (98/100) and Quick Dash scores (2.27% of disability) were excellent, without any decline in motion, strength, and stability, accompanied by no pain.", "summary": "A 25-year-old woman fell from a chair, injuring her left forearm and wrist. On admission, plain roentgenograms of the left upper extremity revealed an anterior, Bado type-1 Monteggia fracture-dislocation associated with an ipsilateral distal radius fracture. The patient underwent surgical treatment of both injuries with a 3.5 limited contact dynamic compression plate for ulna and a 3.5 mm T-type buttress locking plate for distal radius. Intraoperative roentgenogram showed a spontaneous reduction of the ipsilateral dislocated radial head following osteosynthesis. An above, the elbow plaster cast was applied for 2 weeks because of the radial head dislocation. 10 weeks postoperatively the patient regained full range of motion of her wrist, elbow, and supination/pronation in her forearm. 4 months postoperatively she was returned to her previous daily activity after roentgenograms showed complete bone healing.", "subclaim_evaluations": [ { "subclaim": "The patient is a 25-year-old woman.", "support_label": "supported", "is_refined": false }, { "subclaim": "She fell from a chair.", "support_label": "supported", "is_refined": false }, { "subclaim": "She injured her left forearm and wrist.", "support_label": "supported", "is_refined": false }, { "subclaim": "Plain roentgenograms of the left upper extremity were obtained.", "support_label": "supported", "is_refined": false }, { "subclaim": "The roentgenograms revealed an anterior, Bado type-1 Monteggia fracture-dislocation.", "support_label": "supported", "is_refined": false }, { "subclaim": "The roentgenograms revealed an ipsilateral distal radius fracture.", "support_label": "supported", "is_refined": false }, { "subclaim": "The patient underwent surgical treatment of both injuries.", "support_label": "supported", "is_refined": false }, { "subclaim": "A 3.5 limited contact dynamic compression plate was used for the ulna.", "support_label": "supported", "is_refined": false }, { "subclaim": "A 3.5 mm T-type buttress locking plate was used for the distal radius.", "support_label": "supported", "is_refined": false }, { "subclaim": "Intraoperative roentgenogram showed a spontaneous reduction of the ipsilateral dislocated radial head.", "support_label": "supported", "is_refined": false }, { "subclaim": "An above-the-elbow plaster cast was applied.", "support_label": "not_supported", "original_label": "not_supported", "reasoning_audit": "No explicit tags provided.", "is_refined": true }, { "subclaim": "The plaster cast was applied for 2 weeks.", "support_label": "supported", "is_refined": false }, { "subclaim": "The cast was applied because of the radial head dislocation.", "support_label": "not_supported", "original_label": "not_supported", "reasoning_audit": "No explicit tags provided.", "is_refined": true }, { "subclaim": "10 weeks postoperatively, the patient regained full range of motion of her wrist.", "support_label": "supported", "is_refined": false }, { "subclaim": "10 weeks postoperatively, the patient regained full range of motion of her elbow.", "support_label": "supported", "is_refined": false }, { "subclaim": "10 weeks postoperatively, the patient regained full range of supination/pronation in her forearm.", "support_label": "supported", "is_refined": false }, { "subclaim": "4 months postoperatively, roentgenograms showed complete bone healing.", "support_label": "not_supported", "original_label": "not_supported", "reasoning_audit": "No explicit tags provided.", "is_refined": true }, { "subclaim": "4 months postoperatively, the patient was returned to her previous daily activity.", "support_label": "supported", "is_refined": false } ] }, { "id": "multiclinsum_test_374_en.txt", "fulltext": "A 71-year-old man who suffered from CLL was admitted to our hospital on June 23th, 2020 due to fever. In 2001, he was admitted to a hospital due to submaxillary mass. On physical examination, multiple enlarged lymph nodes of the bilateral jaw bone were touched with nontender and of medium in quality, among which the largest lymph node was about 1.0×1.5 cm2. Routine blood results showed white blood cell (WBC) of 148.52×109/L, lymphocyte ratio of 81.5%, hemoglobin of 101 g/L and platelet of 68×109/L. Bone marrow smear revealed active hyperplasia of nucleated cells in bone marrow and increased proportion of lymphocytes, including mature lymphocytes (91%) and immature lymphocytes (2.5%). Likewise, peripheral blood films also suggested significantly augmented proportion of lymphocytes, with 91% of mature lymphocytes and 3% of immature lymphocytes, which was consistent with the bone marrow smear of CLL. Subsequently, the patient was subjected to bone marrow biopsy. Results indicated active bone marrow hyperplasia and nodular or patchy proliferation of mature lymphocytes, without granulocyte, erythrocyte and megakaryocyte, as well as germinal center and macrocell transformation. Flow cytometric immunophenotyping showed CD5(+)81%, CD19(+)70%, CD20(+)25% and CD22(+)8%. Finally, the patient was diagnosed with CLL at Binet C stage and was given 4 courses of combination therapy of rituximab, cyclophosphamide, doxorubicin, vincristine and prednisone (R-CHOP). After discharge, he received daily oral chlorambucil 2 mg for a long time, and the disease was controlled.\nOn May 20th, 2020, the patient revisited the hospital. The bone marrow smear still conformed to CLL, and the bone marrow biopsy indicated that tumor cells were scattered or clustered (10–20%). Flow cytometric immunophenotyping performed on the peripheral blood showed that abnormal cell population accounted for 87.16% of nuclear cells, expressing CD19, CD23, CD5, CD200 and CD22, partially expressed CD20, CD123 and CD11c, and weakly expressing CD81 and CD43, suggesting CLL/small lymphocytic lymphoma (CLL/SLL) phenotype. The karyotype of the chromosome was 45,X,-Y[4]/47,XY,+12[6]/46,XY[15]. Fluorescence in situ hybridization (FISH) showed negative IGH/BCL2, ATM/CEP11, RB-1, CCND1/IGH, CEP12 and P53/CE P17. The second-generation sequencing showed that Y220C and I195F mutations in exon 6 of TP53 mutation were positive, with a mutation rate of 4.1% and 1.5%, respectively. Somatically mutated monoclonal IGHV4-34 gene rearrangement was demonstrated, with 6.7% of mutation rate. Taken together, these findings indicated that this patient was diagnosed with RaiIII-phase CLL at Binet stage C, with IgHV and TP53 mutation. Oral ibrutinib tablet 420 mg was given once a day. No increase in hemoglobin was observed in blood routine monitoring during the oral administration of ibrutinib, and intermittent transfusion for the treatment was conducted in our hospital.\nOn June 23th, 2020, the patient was referred to our hospital when he presented with fever, fatigue and anorexia. On admission, the physical examination revealed anemia, a body temperature of 37.9°C, pulse rate of 102/min, breathing rate of 20 times/min and blood pressure of 120/67 mmHg, without obvious abnormalities in the heart and lungs. There were enlarged lymph nodes in the bilateral neck and groin, with the most being 2×3 cm2, as well as splenomegaly (line A and B of 5 cm, line A and C of 6 cm, line D and V of −6 cm) with small-medium in size, nontender and pitting edema of lower limbs. Routine blood results showed WBC of 59.16×109/L, lymphocyte count of 121.04×109/L, hemoglobin of 89 g/L and neutrophile granulocyte of 17.78×109/L. Bone marrow smear indicated active bone marrow hyperplasia, and we observed 46.5% of protogranulocytes (small and unequal in size and some cytoplasm containing a few azurophilic granules), many basophilic erythroblast, megakaryocytes and small megakaryocytes, but little immature lymphocytes . The positive rate of POX staining was about 65%, indicating CLL accompanied by AML-M2 . As shown in , abnormal myeloid primordial cells were found in the specimens, accounting for 32.86% of the nuclear cells, which was in line with AML phenotype. In addition to expressing myeloid antigens, CD56-positive lymphocytes were also noticed, which could be used as a monitoring indicator for minor residual disease. A cluster of abnormal B lymphocytes with small forward scatter (FSC) intensity and side scatter (SSC) intensity was observed in the specimen of the patients, and the phenotype of the cluster of cells was consistent with CLL/SLL. Moreover, the patient’s karyotype was 44, X,-Y,del(5)(q31),-7add(12)(p13)der(17)der(18), 22,+mar([8]/44,idem,del(4)(q22)[12] .\nOn the basis of the data above, a final diagnosis of AML-M2 secondary to CLL was made, with -Y,del(4q),del(5q),-7,add(12p),der(17),der(18),-22,+mar. Azacitidine combined with B-cell lymphoma 2 (Bcl-2) inhibitor was recommended for the treatment, which was rejected by his family, and the patient died of pulmonary infection on October 17, 2020. This study followed the principles of the Declaration of Helsinki, and informed consent was obtained from the patient’s family.", "summary": "We reported a case of a 71-year-old man with a history of CLL. The patient was administrated with chlorambucil for 19 years and was admitted to our hospital due to fever. Then he was subjected with routine blood tests, bone marrow smear examination, flow cytometric immunophenotyping and cytogenetic analysis. A final diagnosis of AML-M2 secondary to CLL with -Y,del(4q),del(5q),-7,add(12p),der(17),der(18),-22,+mar was made. After rejecting the therapy with Azacitidine combined with B-cell lymphoma-2 (Bcl-2) inhibitor, the patient died of pulmonary infection.", "subclaim_evaluations": [ { "subclaim": "The patient was a 71-year-old man.", "support_label": "supported", "is_refined": false }, { "subclaim": "The patient had a history of chronic lymphocytic leukemia (CLL).", "support_label": "supported", "is_refined": false }, { "subclaim": "The patient was administered chlorambucil for 19 years.", "support_label": "supported", "is_refined": false }, { "subclaim": "The patient was admitted to the hospital due to fever.", "support_label": "supported", "is_refined": false }, { "subclaim": "The patient underwent routine blood tests.", "support_label": "supported", "is_refined": false }, { "subclaim": "The patient underwent bone marrow smear examination.", "support_label": "supported", "is_refined": false }, { "subclaim": "The patient underwent flow cytometric immunophenotyping.", "support_label": "supported", "is_refined": false }, { "subclaim": "The patient underwent cytogenetic analysis.", "support_label": "supported", "is_refined": false }, { "subclaim": "The final diagnosis was AML-M2 secondary to CLL.", "support_label": "supported", "is_refined": false }, { "subclaim": "The karyotype included -Y, del(4q), del(5q), -7, add(12p), der(17), der(18), -22, +mar.", "support_label": "supported", "is_refined": false }, { "subclaim": "The patient rejected therapy with Azacitidine combined with a Bcl-2 inhibitor.", "support_label": "supported", "is_refined": false }, { "subclaim": "The patient died of pulmonary infection.", "support_label": "supported", "is_refined": false } ] }, { "id": "multiclinsum_test_298_en.txt", "fulltext": "A 55-year-old Chinese female was admitted for a 10-month history of painless decline in her vision of the right eye. The patient was initially diagnosed with chronic uveitis and received glucocorticoid-based therapy; however, she responded poorly and was thus referred to our hospital. She reported a transient history of eye redness but no history of photophobia, floaters, flashes, or scotoma in her right eye. During the systemic review of the patient, no symptoms of oral ulcers, vitiligo, alopecia, headaches, or joint pain were revealed. The patient did not experience any eye trauma or surgery.\nHer ophthalmic examination revealed a visual acuity measuring 20/125 OD and 20/25 OS, and her noncontact intraocular pressure values were 13 and 15 mmHg, respectively. The results of both the extraocular appearance and muscle movement examinations were normal. The patient's pupillary light reflex was satisfactory, and her relative afferent pupillary defect was absent. Meticulous slip-lamp examination of the patient's right eye revealed diffuse mutton-fat keratic precipitates, 2 + anterior chamber (AC) cells, and 2 + AC flares. Severe vitreous opacities in the right eye obscured the dilated fundus examination (CLARUS™ 500, Carl Zeiss Meditec AG, Germany) . OCT (Cirrus HD-OCT, Carl Zeiss Meditec, Inc., United States) of the right eye showed high-density reflective spots (indicated by the arrow in Fig. a) in the retinal pigment epithelium (RPE) layer, while Bruch’s membrane remained intact. Spotted hypofluorescence was observed at the posterior pole and mid-peripheral retina, with clustered hyperfluorescent points at the mid-peripheral retina being observed on the ICGA OD . The results of fundoscopy, OCT, or ICGA of her left eye were unremarkable .\nDiagnostic aspiration of the right vitreous was subsequently performed. The cytometric bead array results showed that the ratio of interleukin (IL)-10/IL-6 in the vitreous humour was 1.05, slightly exceeding the upper normal limit (usually set as 1). Specifically, the IL-10 level in the vitreous humour was 39.4 pg/mL, while the IL-6 level was 37.5 pg/mL. The vitreous humour was positive for Epstein–Barr virus (EBV) DNA as determined by the polymerase chain reaction (9.90E + 03 copy/mL), and the vitreous was negative for EBV-IgG. Genetic testing by next-generation sequencing of the vitreous humour revealed several oncogenic mutations, including TP53, JAK2, and FAS. Vitreoretinal lymphoma of the right eye was suspected. Subsequently, whole-body positron emission tomography (PET-CT) showed a hypermetabolic nodule in the retroperitoneal left adrenal area, suggesting a malignant tumour. A core-needle biopsy of the retroperitoneal mass revealed malignant morphological features, including an irregular karyotype, karyokinesis, and karyorrhexis . Further immunohistochemistry and fluorescence in situ hybridization (by a Nikon camera and software, × 400 magnification. Scale bar, 50 μm) proved that the lump was ENKTL; the lump was CD7 + , CD2 + , CD3ε + , CD5-, T-cell intracellular antigen 1 (TIA-1) + , Granzyme B (GrB) + , Ki-67 + and EBV-encoded mRNA (EBER) + . Considering the homology of the two lesions, this patient was confirmed to have metastatic vitreoretinal lymphoma secondary to retroperitoneal ENKTL. Moreover, the positive EBV testing result and oncogenic mutations related to T-cell-derived lymphomas supported the diagnosis. Lymphomatous infiltrates are commonly confined to the space between the RPE and Bruch's membrane in metastatic intraocular ENKTL . Her nasopharyngeal area, a common site for ENKTL, was specifically examined to exclude possible lesions.\nSubsequently, the patient received radiotherapy and sintilimab-based chemotherapy treatment at a tumour specialist hospital. Moreover, 0.4 mg of methotrexate was intravitreally injected into her right eye once a week for two months and once a month for the following three months. At the time of submission, the vision of her right eye was improved from 20/125 to 20/32, and the vitreous opacity was significantly improved, as demonstrated in the fundoscopy photos . OCT at follow-up revealed irregular humps inward into the RPE, while Bruch’s membrane remained intact (indicated by the arrowheads in Fig. c, d). PET-CT reexamination showed that the retroperitoneal nodule decreased in size following treatment, and no new lesions were found.", "summary": "This case report describes a 55-year-old female reporting a 10-month history of painless decline in her vision of the right eye. Optical coherence tomography of the patient revealed hyperreflective nodules and irregular humps in the retinal pigment epithelium layer. The right vitreous was aspirated for diagnostic assessment, revealing an interleukin-10 level of 39.4 pg/mL and an interleukin-10/interleukin-6 ratio of 1.05. The right vitreous humor was positive for Epstein-Barr virus DNA. Upon a systemic examination, a high metabolic nodule was found in the retroperitoneal area and proven to be positive for Epstein-Barr virus-encoded mRNA, CD2, CD3ε, TIA-1, and Ki-67. Considering the homology of the two lesions, the patient was diagnosed with metastatic vitreoretinal lymphoma secondary to retroperitoneal extranodal natural killer/T-cell derived lymphoma. The patient received systemic chemotherapy and regular intravitreal injections of methotrexate. Her visual acuity of the right eye had improved from 20/125 to 20/32 at the latest follow-up. No new lesions were found.", "subclaim_evaluations": [ { "subclaim": "The patient is a 55-year-old female.", "support_label": "supported", "is_refined": false }, { "subclaim": "The patient reported a 10-month history of painless decline in vision of the right eye.", "support_label": "supported", "is_refined": false }, { "subclaim": "Optical coherence tomography revealed hyperreflective nodules in the retinal pigment epithelium layer.", "support_label": "supported", "is_refined": false }, { "subclaim": "Optical coherence tomography revealed irregular humps in the retinal pigment epithelium layer.", "support_label": "supported", "is_refined": false }, { "subclaim": "The right vitreous was aspirated for diagnostic assessment.", "support_label": "supported", "is_refined": false }, { "subclaim": "The interleukin-10 level in the right vitreous was 39.4 pg/mL.", "support_label": "supported", "is_refined": false }, { "subclaim": "The interleukin-10/interleukin-6 ratio in the right vitreous was 1.05.", "support_label": "supported", "is_refined": false }, { "subclaim": "The right vitreous humor was positive for Epstein-Barr virus DNA.", "support_label": "supported", "is_refined": false }, { "subclaim": "A high metabolic nodule was found in the retroperitoneal area.", "support_label": "supported", "is_refined": false }, { "subclaim": "The retroperitoneal nodule was positive for Epstein-Barr virus-encoded mRNA.", "support_label": "supported", "is_refined": false }, { "subclaim": "The retroperitoneal nodule was positive for CD2.", "support_label": "supported", "is_refined": false }, { "subclaim": "The retroperitoneal nodule was positive for CD3ε.", "support_label": "supported", "is_refined": false }, { "subclaim": "The retroperitoneal nodule was positive for TIA-1.", "support_label": "supported", "is_refined": false }, { "subclaim": "The retroperitoneal nodule was positive for Ki-67.", "support_label": "supported", "is_refined": false }, { "subclaim": "The patient was diagnosed with metastatic vitreoretinal lymphoma.", "support_label": "supported", "is_refined": false }, { "subclaim": "The vitreoretinal lymphoma was secondary to retroperitoneal extranodal natural killer/T-cell derived lymphoma.", "support_label": "supported", "is_refined": false }, { "subclaim": "The patient received systemic chemotherapy.", "support_label": "not_supported", "original_label": "not_supported", "reasoning_audit": "No explicit tags provided.", "is_refined": true }, { "subclaim": "The patient received regular intravitreal injections of methotrexate.", "support_label": "supported", "is_refined": false }, { "subclaim": "The patient's visual acuity of the right eye improved from 20/125 to 20/32 at the latest follow-up.", "support_label": "supported", "is_refined": false }, { "subclaim": "No new lesions were found at the latest follow-up.", "support_label": "supported", "is_refined": false } ] }, { "id": "multiclinsum_test_1759_en.txt", "fulltext": "A 57-year-old male presented with 3 months of left pulsatile tinnitus and hemicranial headache without any other neurological deficits. He had no history of head trauma or central nervous system infections. Digital subtraction angiography revealed DAVF with afferents from the left external carotid artery (LECA), notably with the occipital and middle meningeal arteries draining into the ipsilateral sigmoid sinus, without leptomeningeal cortical retrograde venous drainage, and grade I of the Cognard classification .\nThe transvenous approach was chosen, together with closure of the affected sinus using coils, but the surgical team experienced difficulties when passing the microcatheter from the transverse to the sigmoid sinus, which was likely isolated. Thus, two sessions of transarterial embolization were performed 2 months apart . During the first session, the fistulous branch of the left occipital artery was occluded with Onyx® [Figure and ]. The patient recovered uneventfully and tinnitus decreased, although headaches persisted. During the second session conducted with Onyx®, the feeder branch of the left middle meningeal artery was occluded [Figure and ]. Angiography revealed complete exclusion of the fistula and successful embolization . On the first day postoperatively, the patient presented with ipsilateral peripheral facial palsy, House Brackmann grade 4 , and no other physical or neurological signs. Tomography showed no ischemic or hemorrhagic complications . The patient received 4 mg of intravenous dexamethasone every 6 h and showed progressive improvement with complete recovery in 4 days . After 4 months, the patient remains under our care, with no complaints of headache or tinnitus. A follow-up appointment is scheduled for 6 months after his last session.", "summary": "We present a male patient who complained of headaches and left-sided pulsatile tinnitus due to DAVF from the external carotid artery branches draining directly into the ipsilateral sigmoid sinus. Embolization with Onyx® was successful, obtaining angiographic occlusion and symptom remission. However, on postoperative day 4, the patient presented with left facial palsy and spontaneous regression.", "subclaim_evaluations": [ { "subclaim": "The patient is male.", "support_label": "supported", "is_refined": false }, { "subclaim": "The patient complained of headaches.", "support_label": "supported", "is_refined": false }, { "subclaim": "The patient had left-sided pulsatile tinnitus.", "support_label": "supported", "is_refined": false }, { "subclaim": "The cause was a dural arteriovenous fistula.", "support_label": "supported", "is_refined": false }, { "subclaim": "The fistula originated from external carotid artery branches.", "support_label": "supported", "is_refined": false }, { "subclaim": "The fistula drained directly into the ipsilateral sigmoid sinus.", "support_label": "supported", "is_refined": false }, { "subclaim": "Embolization with Onyx® was performed.", "support_label": "supported", "is_refined": false }, { "subclaim": "Angiographic occlusion was achieved.", "support_label": "supported", "is_refined": false }, { "subclaim": "Symptoms resolved after the procedure.", "support_label": "supported", "is_refined": false }, { "subclaim": "On postoperative day 4, the patient developed left facial palsy.", "support_label": "supported", "is_refined": false }, { "subclaim": "The facial palsy spontaneously regressed.", "support_label": "supported", "is_refined": false } ] }, { "id": "multiclinsum_test_1712_en.txt", "fulltext": "An 81-year-old woman, who had a history of resection of a benign eccrine spiradenoma from the parietal scalp 12 years earlier, presented with a large swelling on the same region that had been growing over the preceding 5 years without any neurological deficit. Radiological examinations demonstrated that the lesion was a single, large cystic mass invading bilateral parietal bones and attached to but not occluding the superior sagittal sinus (SSS) . Whole-body positron emission tomography revealed no lymph node or distant metastases.\nThe lesion was excised along with surrounding scalp and bone, and detached from the SSS. The dura mater covering the SSS was electrocoagulated. Reconstruction of the removed skull and scalp was then performed using titanium mesh and a pedicled skin flap from the occipital region which was replaced by a skin graft from the femoral area . Histopathological examination revealed the features of low-grade eccrine SC. Two distinct cell types were observed, comprising eosinophilic cuticular cells surrounded by poroid cells with a high nuclear-cytoplasmic ratio forming palisading or solid nests, accompanied by glandular lumens and ducts. Overall cytoplasmic atypia, some mitotic figures and partial loss of the two-cell structures were also observed . Cytokeratin 7 was broadly expressed, and Ki-67 labeling index was approximately 30% . Close follow-up was continued considering the risk of recurrence.\nThirty-three months after the first surgery, solid tumor was seen to have recurred in the SSS and a second resection was performed . The tumor was totally excised, again preserving the SSS, adjacent dura and pedicled scalp flap . Histopathological diagnosis was similar to the previous lesion, other than the loss of the large cyst formation. No adjuvant therapy was administered, in consideration of the lack of evidence of efficacy, the age of the patient, and a recent history of ischemic brainstem infarction prior to the second surgery.\nTwelve months after the second surgery, a heterogeneous contrast-enhancing mass was observed in the epidural region with extracranial extension pushing against the titanium mesh. The SSS was compressed but not occluded, and the scalp skin was about to rupture . No metastatic lesion was evident on whole-body examination.\nThe third operation was performed with resection of the skin flap, titanium mesh, and surrounding bone edge. The tumor invading the SSS could not be resected due to marked bleeding. An artificial bone flap made from polyethylene was used for the cranioplasty instead of metallic material, which would reduce the scattered radiation dose to the surrounding tissue. Scalp reconstruction was performed with a new pedicled skin flap from the left temporal region . The histopathological diagnosis was compatible with the first lesion. Two months after the third surgery, the patient received 6 MV X-ray EBRT using simultaneous integrated boost (SIB) volumetric-modulated arc therapy (VMAT) with the prescribed dose of 50 Gy in 25 fractions to the planning target volume margin (residual gross tumor invading the SSS + 5 mm, tumor cavity + 3 mm) as well as SIB with 57.5 Gy to the residual gross tumor margin. The median dose to the gross tumor volume was 60.4 Gy. The residual tumor rapidly shrank and had vanished by 3 months after completion of the EBRT .\nTwenty months after the third surgery, the patient developed left hemiparesis and a recurrent tumor was observed with intracerebral extension arising from the SSS forming a cystic lesion . The patient concurrently developed rectal carcinoma with lower gastrointestinal bleeding. Palliative endoscopic partial resection of the cystic lesion was performed, followed by stereotactic radiotherapy using CyberKnife® (Accuray Incorporated, Sunnyvale, CA) with 42.2 Gy in 10 fractions to the margin of the residual cyst wall and the tumor involving the SSS . Histopathological examination demonstrated that the features of low-grade SC had been sustained .\nThe patient was transferred to another hospital and died 7 months after the last treatment, 7 years after the first surgery, with no apparent swelling of the scalp.", "summary": "An 81-year-old woman presented with a large swelling on the parietal scalp 12 years after resection of spiradenoma from the same site. The tumor showed intracranial invasion with involvement of the superior sagittal sinus and repeated recurrences after four surgeries with preservation of the sinus. The histopathological diagnosis was eccrine SC. Adjuvant high-precision external beam radiotherapy (EBRT) proved effective after the third surgery, achieving remission of the residual tumor. The patient died 7 years after the first surgery for SC.", "subclaim_evaluations": [ { "subclaim": "The patient was an 81-year-old woman.", "support_label": "supported", "is_refined": false }, { "subclaim": "She had a large swelling on the parietal scalp.", "support_label": "supported", "is_refined": false }, { "subclaim": "The swelling occurred 12 years after resection of spiradenoma from the same site.", "support_label": "supported", "is_refined": false }, { "subclaim": "The tumor showed intracranial invasion.", "support_label": "supported", "is_refined": false }, { "subclaim": "The tumor involved the superior sagittal sinus.", "support_label": "supported", "is_refined": false }, { "subclaim": "The histopathological diagnosis was eccrine spiradenocarcinoma.", "support_label": "supported", "is_refined": false }, { "subclaim": "Adjuvant high-precision external beam radiotherapy was used after the third surgery.", "support_label": "supported", "is_refined": false }, { "subclaim": "The radiotherapy achieved remission of the residual tumor.", "support_label": "supported", "is_refined": false }, { "subclaim": "The patient died 7 years after the first surgery for spiradenocarcinoma.", "support_label": "supported", "is_refined": false } ] }, { "id": "multiclinsum_test_3037_en.txt", "fulltext": "A 70-year-old female patient with a medical history of fibromyalgia, dystonia, and Sjogren’s disease, presented to our outpatient department complaining of unilateral right wrist joint pain with limited ROM, which worsened over several months. She reported tenderness over the scaphoid. Her active ROM was limited to 20° of dorsal flexion and 10° of palmar flexion, ROM stiffness was observed upon passive movement. A contralateral examination of the left wrist was unremarkable. Her symptoms began two years prior after sustaining a forceful dorsal impact to the wrist. She reported no pain and an intact range of motion before that injury. Initial radiographs did not demonstrate any acute fractures or other abnormalities. The patient was treated nonoperatively with non-steroidal anti-inflammatories (NSAIDs) and physiotherapy.\n\nAt follow-up one year later, the patient had mild improvement in symptoms, but pain persisted. Interval radiographs and computerized tomography (CT) were suggestive of arthritis and sclerosis at the proximal pole of the scaphoid. The scapholunate (SL) and lunotriquetral (LT) joint spaces were not altered. No acute or residual fractures were identified.\n\nIn retrospect, a CT scan revealed a subchondral crescent sign on the scaphoid, suggesting impending articular collapse due to osteonecrosis. The patient continued with non-operative management.\n\nAt two-years of follow-up, wrist pain had not improved. Magnetic resonance imaging (MRI) and repeat radiographs demonstrated diffused altered marrow signals in the scaphoid, which were suggestive of AVN. There was marked flattening of the scaphoid with collapse of the cancellous bone. Once again, no evidence of a fracture was appreciated. The presence of AVN, associated pain, and worsening symptoms were indications for surgical management.\n\nThe patient was consented for proximal row carpectomy. The wrist joint was accessed by a minimally invasive dorsal approach over the fourth extensor compartment with preservation of the retinaculum. The scaphoid, lunate, and triquetrum bones were excised. A neo-articulation between the capitate and lunate fossa of the radius was created. The scaphoid was excised en-bloc and was collapsed and flattened proximally with evidence of fragmentation, but no fracture.\n\nCross-section histological analysis of the scaphoid demonstrated diffuse AVN, suggestive of Preiser’s disease. These findings were supported by intramedullary fat necrosis of the bone with resulting acellular bone trabeculae. Histology further examined the cross sections of the scaphoid bone and discovered the presence of marrow fibrosis.\n\nFor histological analysis, the specimen was placed in 10% buffered formalin for a minimum of 24 h after the operation. Following fixation, the samples were placed in an adequate volume of demineralization solution (Cal-ExTM Decalcifying Fluid, Fisher ChemicalTM) and subsequently checked daily by a histotechnologist until deemed adequately demineralized for routine tissue processing, paraffin embedding, microtomy, and hematoxylin and eosin staining.\n\nPostoperatively, the patient experienced pain relief and improved wrist function. Wrist range of motion was still limited, but improved to injury baseline, and hand therapy was recommended.\n\nThe Herbert and Lanzetta grading scale [9] is used to assess the four stages of Preiser’s disease, beginning with density (sclerotic) changes to the proximal pole of the scaphoid, to complete collapse of the carpal bones with osteoarthritis: Stage I – Normal radiograph and CT, may show MRI signal change; Stage II – Increased sclerotic density of proximal pole of scaphoid; Stage III – Fragmentation of proximal pole of scaphoid without pathologic fracture; Stage IV – Carpal collapse with osteoarthritis. MRI signal changes can be further graded using the Kalainov criteria, whereby Type I and II are differentiated by complete or incomplete necrosis of the scaphoid bone, respectively [10]. In line with these grading scales, our patient had Stage III Herbert and Lanzetta, with Type II Kalainov idiopathic AVN of the scaphoid.", "summary": "We describe a case of Preiser's disease in a 70-year-old female, with worsening pain and loss of range of motion in her right wrist over a two-year period. Past medical history was significant for Sjogren's disease, fibromyalgia, and dystonia. Pain began several months following traumatic right dorsal wrist injury. Diagnosis of traumatic scaphoid fracture was originally suspected. Conservative treatment was unsuccessful. Radiographs did not demonstrate evidence of primary fracture. CT scan and MRI demonstrated osteonecrosis of the proximal pole of the scaphoid, but no evidence of fracture, either residual or healing, was found. Proximal row carpectomy was performed for avascular necrosis of the scaphoid. Histology confirmed diagnosis and verified absence of fracture. Postoperatively, the patient's pain and range of motion improved.", "subclaim_evaluations": [ { "subclaim": "The patient is a 70-year-old female.", "support_label": "supported", "is_refined": false }, { "subclaim": "She had worsening pain in her right wrist over a two-year period.", "support_label": "supported", "is_refined": false }, { "subclaim": "She had loss of range of motion in her right wrist.", "support_label": "supported", "is_refined": false }, { "subclaim": "Her past medical history included Sjogren's disease.", "support_label": "supported", "is_refined": false }, { "subclaim": "Her past medical history included fibromyalgia.", "support_label": "supported", "is_refined": false }, { "subclaim": "Her past medical history included dystonia.", "support_label": "supported", "is_refined": false }, { "subclaim": "Pain began several months after a traumatic right dorsal wrist injury.", "support_label": "supported", "is_refined": false }, { "subclaim": "Traumatic scaphoid fracture was originally suspected.", "support_label": "not_supported", "original_label": "not_supported", "reasoning_audit": "No explicit tags provided.", "is_refined": true }, { "subclaim": "Conservative treatment was unsuccessful.", "support_label": "supported", "is_refined": false }, { "subclaim": "Radiographs did not show evidence of primary fracture.", "support_label": "supported", "is_refined": false }, { "subclaim": "CT scan showed osteonecrosis of the proximal pole of the scaphoid.", "support_label": "supported", "is_refined": false }, { "subclaim": "MRI showed osteonecrosis of the proximal pole of the scaphoid.", "support_label": "supported", "is_refined": false }, { "subclaim": "No evidence of fracture was found.", "support_label": "supported", "is_refined": false }, { "subclaim": "Proximal row carpectomy was performed.", "support_label": "supported", "is_refined": false }, { "subclaim": "The procedure was for avascular necrosis of the scaphoid.", "support_label": "supported", "is_refined": false }, { "subclaim": "Histology confirmed the diagnosis.", "support_label": "supported", "is_refined": false }, { "subclaim": "Histology verified absence of fracture.", "support_label": "supported", "is_refined": false }, { "subclaim": "Postoperatively, the patient's pain improved.", "support_label": "supported", "is_refined": false }, { "subclaim": "Postoperatively, the patient's range of motion improved.", "support_label": "supported", "is_refined": false } ] }, { "id": "multiclinsum_test_634_en.txt", "fulltext": "A 43-year-old man visited our hospital with left facial swelling involving the buccal and submandibular areas.\nA 43-year-old male patient was admitted to our outpatient department complaining of swelling and pain in the left hemifacial area which started two weeks prior to consult. The patient had fever for approximately 10 d, but no other systemic symptoms occurred. At the time of the visit, the patient had fever with a temperature of 38.0 °C.\nThe patient was diagnosed with diabetes mellitus treated with insulin. In addition, the patient had no history of illness associated with CNF, such as dental procedures, including tooth extraction, skin trauma, head and neck infections, and other facial fractures.\nThe patient had no medical history other than diabetes mellitus, and no family history of CNF.\nPreoperative: On physical examination, trismus and thinning of the skin with crepitation were observed on the left cheek. There were also no pathological findings on dental examination.\nPostoperative: On postoperative day (POD) 1, after surgical decompression by incision and drainage, the patient’s systemic condition worsened, accompanied by tachycardia, hypotension, and overall deterioration of the patient’s condition; hence, septic shock was considered.\nAt the time of hospitalization, the glycated hemoglobin (HbA1C) level was elevated at 17.1, indicating uncontrolled diabetes. The Laboratory Risk Indicator for Necrotizing Fasciitis (LRINEC) scoring system was used for proper diagnosis of necrotizing fasciitis. Laboratory findings showed a high white blood cell (WBC) count (15170/μL; LRINEC score 1 point), a low hemoglobin level (10.5 g/dL; LRINEC score 2 points), an elevated high-sensitivity C-reactive protein (hs-CRP) level (212.94 mg/L; LRINEC score 4 points), a high glucose level (242 mg/dL; LRINEC score 1 point), and a slightly low sodium level (134 mmol/L; LRINEC score 2 points). The following results were normal: Creatinine, bilirubin, aspartate aminotransferase, and alanine aminotransferase. The patient had a score of 10 points in the LRINEC, indicating a high risk of CNF. In addition, the albumin level was low at 2.3 g/dL. Procalcitonin, measured on the 3rd d after admission, was elevated at 1.140 ng/mL (normal range: < 0.1 ng/mL). Blood cultures after admission, wound swabs, and tissue cultures of the surgical field showed gram-negative Klebsiella pneumoniae (K. pneumoniae).\nPreoperative: On facial CT, multiple abscesses with air bubble in the left temporal, masticator, and buccal spaces along the fascial layer were observed . Pleomorphic wall-enhancing lesions were also observed in the left masseter and temporalis muscles .\nPostoperative: On POD 1, follow-up CT revealed that the abscess pocket had become smaller. However, after decompression of the CNF, the patient’s general condition deteriorated and progressed to septic shock. Contrast-enhanced chest CT was performed because multiple nodules were observed on chest X-ray upon admission . On chest CT on POD 2, septic emboli and pneumonia were observed in both lungs . In addition, a lesion suspected as renal abscess was observed on chest CT. On POD 3, contrast-enhanced abdominopelvic CT (APCT) was also done, which showed multiple variably-sized renal abscesses in both kidneys . This raised the suspicion that septic pneumonia and renal abscesses were the sources of sepsis.", "summary": "A 43-year-old man visited our hospital with left hemifacial swelling involving the buccal and submandibular areas. The patient had fever for approximately 10 d before visiting the hospital, but did not report any other systemic symptoms. Computed tomography scan demonstrated an abscess with gas formation. After surgical drainage of the facial abscess, the patient's systemic condition worsened and progressed to septic shock. Further examination revealed pulmonary and renal abscesses. Renal percutaneous catheter drainage was performed at the renal abscess site, which caused improvement of symptoms. The patient showed no evidence of systemic complications during the 4-mo post-operative follow-up period.", "subclaim_evaluations": [ { "subclaim": "The patient is a 43-year-old man.", "support_label": "supported", "is_refined": false }, { "subclaim": "The patient had left hemifacial swelling involving the buccal and submandibular areas.", "support_label": "supported", "is_refined": false }, { "subclaim": "The patient had fever for approximately 10 days before visiting the hospital.", "support_label": "supported", "is_refined": false }, { "subclaim": "Computed tomography scan demonstrated an abscess with gas formation.", "support_label": "supported", "is_refined": false }, { "subclaim": "Surgical drainage of the facial abscess was performed.", "support_label": "supported", "is_refined": false }, { "subclaim": "The patient's systemic condition worsened after surgical drainage.", "support_label": "supported", "is_refined": false }, { "subclaim": "The patient progressed to septic shock.", "support_label": "supported", "is_refined": false }, { "subclaim": "Pulmonary abscesses were found.", "support_label": "not_supported", "original_label": "not_supported", "reasoning_audit": "No explicit tags provided.", "is_refined": true }, { "subclaim": "Renal abscesses were found.", "support_label": "supported", "is_refined": false }, { "subclaim": "Renal percutaneous catheter drainage was performed.", "support_label": "not_supported", "original_label": "not_supported", "reasoning_audit": "No explicit tags provided.", "is_refined": true }, { "subclaim": "The patient showed improvement of symptoms after renal percutaneous catheter drainage.", "support_label": "not_supported", "original_label": "not_supported", "reasoning_audit": "No explicit tags provided.", "is_refined": true }, { "subclaim": "The patient had no evidence of systemic complications during the 4-month post-operative follow-up period.", "support_label": "not_supported", "original_label": "not_supported", "reasoning_audit": "No explicit tags provided.", "is_refined": true } ] }, { "id": "multiclinsum_test_1523_en.txt", "fulltext": "A 20-years-old, British, male sustained cervical spinal cord injury (ASIA impairment scale B) at C-5 level in 1970 while teaching gymnastics. He was a physical training instructor in army and he landed on the wrong side of a trampoline. This gentleman had been managing his bladder by penile sheath drainage until 2013 when he underwent surgery for upper gastrointestinal bleeding. Since then, he had been draining urine by urethral Foley catheter.\nFollowing a routine change of urethral catheter by a health professional, this patient started sweating profusely. The Foley catheter was draining urine; there was no bypassing, no bleeding per urethra, and no haematuria. Patient’s wife, who had been looking after her tetraplegic husband for more than forty years, told the health professionals that the catheter might have been placed incorrectly but her concerns were ignored by health professionals. Therefore, this patient came to spinal unit for advice. On clinical examination, this patient was sweating profusely over his head and face. Blood pressure was 140/70 mm Hg. The patient did not have symptoms of urine infection nor did he feel unwell. Ultrasound scan of urinary tract revealed no urinary calculi, no hydronephrosis. The balloon of Foley catheter was not seen in urinary bladder but this finding was not recognised by radiologist and spinal cord physician. Patient continued to sweat profusely; therefore, Computed Tomography (CT) of pelvis was performed, but there was a delay of ten days. Special attention was taken to include the entire urethra in addition to urinary bladder for scanning, as misplacement of urethral catheter was suspected by the spinal cord physician. CT revealed the balloon of Foley catheter in the over-stretched prostato-membranous urethra . The tip of Foley catheter was not located within the urinary bladder but was lying distal to bladder neck . Flexible cystoscopy was performed and Foley catheter was inserted into the bladder over a guide wire. The intensity of sweating decreased; noxious stimuli arising from traumatised urethra might take a long while to settle.\n24-hours ECG monitoring revealed bradycardia: slowest being 39 beats per minute , 214 episodes, and 36 beats at 00:09:04. There was a pause of 2.08 seconds at 22:14:51 . X-ray of pelvis revealed marked osteoarthritic changes in both hips; X-ray of lumbar spine revealed slight scoliosis concave to the right; anterior hyperostosis, most marked at L4/5; disc spacing was well maintained.\nUltrasound scan revealed normal size right kidney measuring 12.5 cm with no hydronephrosis or calculi. The left kidney was atrophic measuring 8.4 cm, cortical depth of 14.1 mm. No calculus was seen. Blood tests: Urea: 5.9 mmol/L; Creatinine: 69 micromol/L; HbA1c: 36 mmol/mol; PSA: 0.15 ug/L. Urine culture yielded growth of >108/L of Staphylococcus aureus. Cytology of urine revealed abundant neutrophils and red cells. Groups of urothelial cells were seen with slightly enlarged nuclei. Some of the groups have a vaguely papillary appearance, which could be seen in low-grade urothelial neoplasms, infection, instrumentation or stones. A follow-up urine cytology revealed a few inflammatory cells and urothelial cells. No malignant cells were seen.", "summary": "A tetraplegic patient started sweating profusely following insertion of a Foley catheter per urethra. The catheter was draining urine; there was no bypassing, no bleeding per urethra, and no haematuria. Patient's wife, who had been looking after her tetraplegic husband for more than forty years, told the health professionals that the catheter might have been placed incorrectly but her concerns were ignored. Ultrasound scan of urinary tract revealed no urinary calculi, no hydronephrosis. The balloon of Foley catheter was not seen in urinary bladder but this finding was not recognised by radiologist and spinal cord physician. Patient continued to sweat profusely; therefore, CT of pelvis was performed, but there was a delay of ten days. CT revealed the balloon of Foley catheter in the over-stretched prostate-membranous urethra; the tip of catheter was not located within the urinary bladder but was lying distal to bladder neck. Flexible cystoscopy was performed and Foley catheter was inserted into the bladder over a guide wire. The intensity of sweating decreased; noxious stimuli arising from traumatised urethra might take a long while to settle.", "subclaim_evaluations": [ { "subclaim": "The patient is tetraplegic.", "support_label": "supported", "is_refined": false }, { "subclaim": "The patient started sweating profusely after insertion of a Foley catheter per urethra.", "support_label": "supported", "is_refined": false }, { "subclaim": "The catheter was draining urine.", "support_label": "supported", "is_refined": false }, { "subclaim": "There was no bypassing of the catheter.", "support_label": "supported", "is_refined": false }, { "subclaim": "There was no bleeding per urethra.", "support_label": "supported", "is_refined": false }, { "subclaim": "There was no haematuria.", "support_label": "supported", "is_refined": false }, { "subclaim": "The patient's wife had been caring for her husband for more than forty years.", "support_label": "supported", "is_refined": false }, { "subclaim": "The patient's wife suggested the catheter might have been placed incorrectly.", "support_label": "supported", "is_refined": false }, { "subclaim": "The wife's concerns were ignored.", "support_label": "supported", "is_refined": false }, { "subclaim": "An ultrasound scan of the urinary tract showed no urinary calculi.", "support_label": "supported", "is_refined": false }, { "subclaim": "The ultrasound scan showed no hydronephrosis.", "support_label": "supported", "is_refined": false }, { "subclaim": "The balloon of the Foley catheter was not seen in the urinary bladder.", "support_label": "supported", "is_refined": false }, { "subclaim": "The radiologist did not recognize the balloon's location.", "support_label": "supported", "is_refined": false }, { "subclaim": "The spinal cord physician did not recognize the balloon's location.", "support_label": "supported", "is_refined": false }, { "subclaim": "The patient continued to sweat profusely.", "support_label": "supported", "is_refined": false }, { "subclaim": "A CT of the pelvis was performed.", "support_label": "supported", "is_refined": false }, { "subclaim": "There was a ten-day delay before the CT was performed.", "support_label": "supported", "is_refined": false }, { "subclaim": "The CT revealed the balloon of the Foley catheter in the over-stretched prostate-membranous urethra.", "support_label": "supported", "is_refined": false }, { "subclaim": "The tip of the catheter was not located within the urinary bladder.", "support_label": "supported", "is_refined": false }, { "subclaim": "The tip of the catheter was lying distal to the bladder neck.", "support_label": "supported", "is_refined": false }, { "subclaim": "Flexible cystoscopy was performed.", "support_label": "supported", "is_refined": false }, { "subclaim": "The Foley catheter was inserted into the bladder over a guide wire.", "support_label": "supported", "is_refined": false }, { "subclaim": "The intensity of sweating decreased after the catheter was correctly placed.", "support_label": "supported", "is_refined": false }, { "subclaim": "Noxious stimuli from the traumatised urethra might take a long while to settle.", "support_label": "supported", "is_refined": false } ] }, { "id": "multiclinsum_test_1756_en.txt", "fulltext": "A 76-year-old Caucasian female with known hypertension and dyslipidaemia presented with 2 weeks of intermittent palpitations, orthopnoea, and New York Heart Association functional class III–IV shortness of breath. On exam, the patient was not in acute distress; however, extremities were cool and clammy. Heart auscultation revealed normal heart sounds, no murmurs, rubs, or gallops but the rhythm was irregularly irregular at ∼100 b.p.m. The jugular venous pressure was elevated at the angle of the jaw and there was a positive abdominojugular reflux sign. Auscultation of the lungs revealed bilateral crackles up to mid chest with decreased air entry at the bases. The abdomen was soft, non-tender, and non-distended.\nIn the emergency department, she was in uncontrolled atrial fibrillation (AF) with a left bundle branch block with clinical evidence of decompensated heart failure and her chest X-ray confirming evidence of pulmonary oedema with bilateral pleural effusions. There was no prior electrocardiogram for comparison. She was admitted for intravenous diuresis [initially with Furosemide 80 mg intravenously (IV) once then Furosemide infusion 20 mg/h] and rate control (initially with metoprolol 5 mg IV once then transitioned to oral metoprolol with an intravenous digoxin load). Over the next few hours, she became increasingly diaphoretic, tachycardic, and hypotensive at 60/30 mmHg. High-sensitivity troponin increased to 2040 ng/L (reference value ≤30 ng/L) from 13 ng/L, and serum lactate was 7.1 mmol/L (reference value 0.5–2.2 mmol/L). She also developed anuric acute kidney injury with an increase in serum creatinine from 58 to 122 μmol/L (reference value 50–98 μmol/L). Other admission labs are shown in . She was started on dual antiplatelet therapy (ASA 81 mg orally daily, clopidogrel 75 mg orally daily, and fondaparinux 2.5 mg subcutaneously daily) for suspected acute coronary syndrome and vasopressors to maintain perfusion. Point-of-care ultrasound demonstrated significant biventricular systolic dysfunction, a plethoric non-collapsible inferior vena cava, and diastolic flattening of the interventricular septum suggesting volume overload of the right ventricle.\nThe following differential diagnoses were considered at that time:\nAcute coronary syndrome and possible mechanical complication with right ventricular (RV) infarction.\nUnderlying cardiomyopathy and/or pulmonary hypertension and superimposed acute decompensation.\nMassive pulmonary embolism.\nAs the patient was in extremis, she was intubated for emergent cardiac catheterization. She was initiated on epinephrine, norepinephrine, and vasopressin prior to arrival to the catheterization lab. Angiographically, the left main coronary artery (LMCA), left anterior descending (LAD), and left circumflex (LCx) arteries were very large, ectatic vessels with no flow-limiting stenosis. The right coronary artery (RCA) ostium could not be engaged from the aorta despite multiple attempts. Contrast injection into the left coronary system showed what appeared to be retrograde filling of the RCA via multiple left-to-right collateral vessels ( and Video 1A and B). On further review, it was felt that the RCA was emptying back into the pulmonary artery/right ventricular outflow tract (RVOT).\nThe possibility of an anomalous coronary artery (ACA) as the underlying aetiology of the patient’s shock prompted an ad hoc right heart catheterization for haemodynamic assessment. Measurements are shown in . An oximetry run did not suggest the presence of an intra-cardiac left-to-right shunt. Pulmonary artery angiography did not identify any pulmonary embolus or fistula involving the RVOT. The pulmonary vascular resistance was 0.87 Wood units and the systemic vascular resistance was 6.39 Wood units. An RV angiogram demonstrated significant tricuspid regurgitation (TR) with a dilated and severely dysfunctional right ventricle. It was felt that the cause of the patient’s cardiogenic shock was due to underlying severe RV dysfunction with either AF or other catecholaminergic state triggering decompensation. The elevated cardiac index prompted consideration of sepsis on the differential diagnosis and the patient accordingly received empiric antibiotics (Piperacillin/Tazobactam 4.5 g IV every 6 h, Vancomycin 1 g IV every 12 h, and Doxycycline 100 mg orally twice daily). She returned to the cardiovascular intensive care unit (CVICU) for further physiologic support.\nFormal echocardiography while in the CVICU demonstrated severely reduced RV systolic function, right atrial dilatation, and severe TR. The overall left ventricular systolic function was low-normal with an ejection fraction between 50% and 55% and no regional wall motion abnormalities. A transoesophageal echocardiogram ruled out vegetations but corroborated findings from the patient’s cardiac catheterization including a dilated and tortuous LMCA and branches, as well as a dilated and tortuous vessel draining into the pulmonary artery. This vessel was felt to be likely the RCA. Overall, these findings were consistent with a diagnosis of ARCAPA (see and Video 2).\nIn the CVICU, the patient was maintained on inotropes and vasopressors. High-sensitivity troponin plateaued at 26 040 ng/L and this was felt to be consistent with an RV infarction. In the setting of concomitant volume overload and anuric acute kidney injury, continuous renal replacement therapy was initiated. She was subsequently found to be bacteremic with positive blood cultures for Streptococcus bovis but not stable enough to pursue a colonoscopy to rule out a gastrointestinal malignancy; management consisted of antimicrobial therapy (ceftriaxone/metronidazole) with consultation from infectious diseases.\nThe patient’s clinical status eventually stabilized enough to be extubated and transferred to the cardiology ward, although she remained dependent on intermittent haemodialysis without expected renal recovery. Potential therapeutic options for ARCAPA were discussed at interdisciplinary heart team rounds but unfortunately, she was felt not to be a surgical candidate in view of her age and clinical status. The patient decided to pursue comfort measures and requested cessation of dialysis. She was transferred to a hospice for palliative care and passed away just over a month later.", "summary": "We present a case of a 76-year-old female presenting with 2 weeks of palpitations and shortness of breath who was found to be in rapid atrial fibrillation (AF) with congestive heart failure. Despite initial medical management, the patient developed cardiogenic shock with anuric renal failure. Emergent right and left heart catheterization did not demonstrate any significant obstructive coronary artery disease but showed severe right ventricular (RV) failure and raised the possibility of an ARCAPA. This diagnosis was further corroborated by findings on a subsequent transoesophageal echocardiogram. In view of profound decline and limited anticipated improvement, the patient ultimately decided to pursue comfort measures in a hospice setting.", "subclaim_evaluations": [ { "subclaim": "The patient is a 76-year-old female.", "support_label": "supported", "is_refined": false }, { "subclaim": "She had 2 weeks of palpitations.", "support_label": "supported", "is_refined": false }, { "subclaim": "She had shortness of breath.", "support_label": "supported", "is_refined": false }, { "subclaim": "She was found to be in rapid atrial fibrillation.", "support_label": "supported", "is_refined": false }, { "subclaim": "She had congestive heart failure.", "support_label": "supported", "is_refined": false }, { "subclaim": "She developed cardiogenic shock.", "support_label": "supported", "is_refined": false }, { "subclaim": "She developed anuric renal failure.", "support_label": "supported", "is_refined": false }, { "subclaim": "Emergent right and left heart catheterization did not show significant obstructive coronary artery disease.", "support_label": "supported", "is_refined": false }, { "subclaim": "The catheterization showed severe right ventricular failure.", "support_label": "supported", "is_refined": false }, { "subclaim": "The catheterization raised the possibility of an ARCAPA.", "support_label": "supported", "is_refined": false }, { "subclaim": "A transoesophageal echocardiogram corroborated the ARCAPA diagnosis.", "support_label": "supported", "is_refined": false }, { "subclaim": "The patient decided to pursue comfort measures.", "support_label": "supported", "is_refined": false }, { "subclaim": "The patient chose hospice care.", "support_label": "supported", "is_refined": false } ] }, { "id": "multiclinsum_test_2523_en.txt", "fulltext": "A 69-year-old female presented with chest and severe upper back pain, but neurologically intact. The first chest computed tomography (CT) was interpreted as normal . Over the next 2 months, she progressively developed anorexia and the inability to belch. Esophageal stricture and thoracic vertebra OVF were suspected based on the results of the second chest CT . Thoracic magnetic resonance (MR) and CT studies revealed a T7 OVF with a kyphotic deformity . Twice, she underwent esophagogastroscopy that showed no obstruction. As her symptoms were attributed, therefore, to the T7 OVF, she underwent a T7 BKP resulting in an improved kyphotic angle from 22.4 degrees to 17 degrees . In addition, this resulted in resolution of her symptoms.", "summary": "A 69-year-old female presented with back pain. 2 months later, she developed anorexia and difficulty belching. The thoracic magnetic resonance (MR) demonstrated a T7 OVF. As she ultimately underwent a balloon kyphoplasty (BKP), as conservative treatment was unsuccessful.", "subclaim_evaluations": [ { "subclaim": "The patient is a 69-year-old female.", "support_label": "supported", "is_refined": false }, { "subclaim": "She presented with back pain.", "support_label": "supported", "is_refined": false }, { "subclaim": "Two months later, she developed anorexia.", "support_label": "supported", "is_refined": false }, { "subclaim": "She had difficulty belching.", "support_label": "supported", "is_refined": false }, { "subclaim": "The thoracic MR demonstrated a T7 OVF.", "support_label": "supported", "is_refined": false }, { "subclaim": "She ultimately underwent a balloon kyphoplasty.", "support_label": "supported", "is_refined": false }, { "subclaim": "Conservative treatment was unsuccessful.", "support_label": "supported", "is_refined": false } ] }, { "id": "multiclinsum_test_2173_en.txt", "fulltext": "A 47-year-old woman presented with complex bilateral renal stones and was referred to our hospital for surgical treatment due to failure of conventional PCNL performed at another hospital. Initially, we performed mini-ECIRS for the right renal stone, which was later identified as calcium oxalate, without any complications and residual stones.\nThree months after the first mini-ECIRS, she underwent a second mini-ECIRS for the left renal stone. Laboratory studies showed normal values of serum inflammatory markers, liver and renal function, mineral markers, and urinary parameters. Multi-slice computed tomography and kidney-ureter-bladder radiography revealed a stone (size, 6.5 × 2.2 × 2.4 cm3) with left calyceal fragment . Mini-ECIRS was performed in the prone position, and supra-12th rib access was obtained with a single pass of the 16.5/17.5-Fr metal sheath with a 12-Fr nephroscope under combined US and ureteroscopy guidance. During puncture, we identified the pleural space and pleural line under US to avoid penetration. After puncture, we checked intraoperative fluoroscopy to evaluate potential chest complications. Using the holmium YAG-laser through the rigid nephroscope, all parts of the collecting system and a part of the main stone were cleared. Finally, an ureteral stent without a nephrostomy tube was placed after the procedure. The operative time was 3 h, with no intraoperative complications and an estimated blood loss of <100 cc.\nOn POD 1, the patient developed shortness of breath. Tachypnea with normal vital signs was noted with deteriorating breath sounds on the left side. Chest radiography confirmed left pleural collection . Her hemoglobin level, which was 12.0 g/dL at discharge, had dropped to 11.0 g/dL. On consultation with the thoracic surgeon, she was conservatively managed without any treatment for several days. On POD 5, a 16-Fr tube was placed for left intercostal drainage under local anesthesia with ultrasonography guidance by the standard technique because of the aggravation of hemothorax . A small volume of old blood was drained without improved expansion of the left lower and middle lobes . On POD 9, VATD was performed for the hemothorax. During intraoperative monitoring, some abscesses were observed in the hemothorax, which appeared to be empyema; moreover, a scar hole that had been punctured through the pleural cavity during mini-ECIRS was identified . Thereafter, blood clot evacuation, decortication, and ablation were performed by VATD. At the end of the procedure, the 20-Fr chest tubes were retained . On POD 14, she was discharged after retrieval of the chest tube. Follow-up evaluation showed satisfactory expansion of the left lung with complete resolution of all chest symptoms .", "summary": "A 47-year-old woman with left staghorn kidney stone underwent mini-endoscopic combined intrarenal surgery, after which she developed shortness of breath. Chest radiography and computed tomography confirmed left hemothorax. Conservative management and left intercostal chest drainage were performed without improvement. Subsequently, video-assisted thoracoscopic debridement was performed.", "subclaim_evaluations": [ { "subclaim": "The patient is a 47-year-old woman.", "support_label": "supported", "is_refined": false }, { "subclaim": "The patient had a left staghorn kidney stone.", "support_label": "supported", "is_refined": false }, { "subclaim": "The patient underwent mini-endoscopic combined intrarenal surgery.", "support_label": "supported", "is_refined": false }, { "subclaim": "The patient developed shortness of breath after the surgery.", "support_label": "supported", "is_refined": false }, { "subclaim": "Chest radiography was performed.", "support_label": "supported", "is_refined": false }, { "subclaim": "Computed tomography was performed.", "support_label": "supported", "is_refined": false }, { "subclaim": "Chest imaging confirmed left hemothorax.", "support_label": "supported", "is_refined": false }, { "subclaim": "Conservative management was performed.", "support_label": "supported", "is_refined": false }, { "subclaim": "Left intercostal chest drainage was performed.", "support_label": "supported", "is_refined": false }, { "subclaim": "There was no improvement after conservative management and chest drainage.", "support_label": "supported", "is_refined": false }, { "subclaim": "Video-assisted thoracoscopic debridement was performed.", "support_label": "supported", "is_refined": false } ] }, { "id": "multiclinsum_test_927_en.txt", "fulltext": "We report here two cases of pulmonary hypertension after the second dose of the Pfizer mRNA COVID-19 vaccine (BNT162b2).\nCase #1 is a previously healthy 49-year-old male physician athlete, body mass index (BMI) 23, non-smoker with a history of mild exercise-induced asthma treated with albuterol. The patient completed the primary series of Pfizer mRNA COVID-19 vaccine (BNT162b2), Dose 1 in December 2020 and Dose 2 in January 2021. Approximately three weeks after the second dose, the patient suddenly developed severe fatigue, flu-like symptoms, tachycardia, palpitations, orthostasis, right-sided chest pressure and dyspnea on exertion. SARS-CoV-2 polymerase chain reaction (PCR) testing was negative at the time of the onset of these symptoms. Transthoracic echocardiogram revealed normal left ventricular function with an ejection fraction (EF) of 65%, normal right ventricular size and function and a maximal tricuspid regurgitation velocity (TRVmax) of 3.09 m/s. The estimated right ventricular systolic pressure (RVSP) of 42 mmHg was interpreted as mild/moderate pulmonary hypertension . Laboratory studies including measurement of brain natriuretic peptide (BNP) (22 pg/mL; reference range < 900 pg/mL) were unremarkable except for elevated low-density lipoprotein (LDL) cholesterol and a hematocrit of 50%. Pulmonary computer tomography (CT) angiogram with 3D reconstruction of the PA tree was normal without evidence of pulmonary clots . The patient subsequently developed 15 lbs of fluid gain and generalized swelling, neck pressure, headaches and a feeling of “being hung upside down” consistent with jugular vein distention (JVD) and cerebral venous congestion. The resting oxygen saturation (SpO2) was 92% and there was new onset systolic and diastolic arterial hypertension. Symptoms and chest pressure occurred at rest and were exacerbated by exertion. Exercise and functional limitations were consistent with New York Heart Association (NYHA) Class 3–4. Serial echocardiograms showed no worsening of RVSP and continued normal RV function . Symptoms and exercise tolerance improved to NYHA class 1–2 over one year. Fluid weight gain, swelling, tachycardia and arterial hypertension resolved and the resting SpO2 increased to 98–100%. Flu-like symptoms and fatigue diminished but did not disappear. RVSP remained elevated and essentially unchanged by follow up echocardiography . This case was reported to the Vaccine Adverse Event Reporting System (VAERS ID 1039123).\nCase #2 is a previously healthy and active 56-year-old male, BMI 25, non-smoker, with a history of spontaneous deep venous thrombosis (DVT) on two occasions which were resolved with courses of anticoagulation without symptoms of pulmonary emboli. Hematologic investigation identified no clotting abnormalities. In 2005, an incidental isolated left superior vena cava was suspected by an otherwise normal transthoracic echocardiogram and confirmed by cardiac magnetic resonance imaging (MRI). The patient completed the primary series of Pfizer mRNA COVID-19 vaccine (BNT162b2) Dose 1 and Dose 2 in April 2021. Twelve days after the second dose, the patient experienced sudden onset fatigue, flu-like symptoms and dyspnea on exertion. SARS-CoV-2 PCR testing was negative at the time of the onset of these symptoms. Exercise tolerance was consistent with NYHA Class 2. The patient sought medical attention two weeks later, but a stress echocardiogram and CT pulmonary angiography were not performed until almost 4 months after vaccination. The stress echocardiogram revealed normal left ventricular function, an ejection fraction (EF) of 60%, ventricular ectopy and mild right-sided chamber enlargement. No right-sided pressures were measured. A pulmonary CT angiogram with 3D reconstruction revealed mosaic attenuation of lung parenchyma with relative pruning of distal pulmonary vessels and mild enlargement of the PA without evidence of pulmonary emboli . A Ventilation Perfusion (V/Q) scan was interpreted as near normal and a very low probability for pulmonary emboli. Despite the negative studies, anti-coagulation with rivaroxaban was started out of an abundance of caution due to patient’s distant history of DVT. A complete echocardiogram performed 5 months after vaccination measured a TRVmax of 2.82 m/s and calculated an RVSP of 40 mm Hg , suggesting a diagnosis of pulmonary hypertension. Follow-up echocardiography three months later measured a TRVmax of 3.22 m/s and estimated an RVSP of 46 mmHg . Subsequent right heart catheterization confirmed the diagnosis with directly measured systolic and diastolic PA pressures (PAP) of 44/18 mm Hg (mean 28 mm Hg) and elevated pulmonary vascular resistance (PVR) calculated at 3.6 Woods units. An endothelin receptor antagonist was prescribed and then a phosphodiesterase inhibitor. Fifteen months after vaccination, the patient’s exercise tolerance remained unchanged and consistent with NYHA Class 2 and the RVSP remained elevated at 49 mm Hg, estimated by a TRVmax of 3.22 m/s . The patient’s course was complicated by transient episodes of new onset atrial fibrillation. BNP remained in normal range at 99 pg/mL. A subsequent Cardiac MRI revealed a mildly enlarged right ventricle with normal systolic function and normal main PA. A pulmonary hypertension screening panel by Invitae Genomics was negative for twelve genetic predisposition markers.\nThe clinical findings of the two cases are summarized in .", "summary": "Pulmonary hypertension in previously healthy adult males occurred within three weeks of receiving the second dose of the Pfizer (BNT162b2) mRNA COVID-19 vaccine from different lots. Both patients experienced a sudden onset of severe fatigue and dyspnea on exertion with negative severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) polymerase chain reaction (PCR) testing. The diagnosis was made by serial transthoracic echocardiography in the first case and by both transthoracic echocardiography and right heart catheterization in the second. Both cases resulted in functional limitations and likely permanent organ damage. No evidence of pulmonary emboli was detected in either case.", "subclaim_evaluations": [ { "subclaim": "Two previously healthy adult males developed pulmonary hypertension.", "support_label": "supported", "is_refined": false }, { "subclaim": "The pulmonary hypertension occurred within three weeks of receiving the second dose of the Pfizer (BNT162b2) mRNA COVID-19 vaccine.", "support_label": "supported", "is_refined": false }, { "subclaim": "The vaccines were from different lots.", "support_label": "not_supported", "original_label": "not_supported", "reasoning_audit": "No explicit tags provided.", "is_refined": true }, { "subclaim": "Both patients experienced sudden onset of severe fatigue.", "support_label": "supported", "is_refined": false }, { "subclaim": "Both patients experienced dyspnea on exertion.", "support_label": "supported", "is_refined": false }, { "subclaim": "Both patients had negative SARS-CoV-2 PCR testing.", "support_label": "supported", "is_refined": false }, { "subclaim": "The diagnosis was made by serial transthoracic echocardiography in the first case.", "support_label": "supported", "is_refined": false }, { "subclaim": "The diagnosis was made by right heart catheterization in the second case.", "support_label": "supported", "is_refined": false }, { "subclaim": "Both cases resulted in functional limitations.", "support_label": "supported", "is_refined": false }, { "subclaim": "Both cases likely resulted in permanent organ damage.", "support_label": "not_supported", "original_label": "not_supported", "reasoning_audit": "No explicit tags provided.", "is_refined": true }, { "subclaim": "No evidence of pulmonary emboli was detected in either case.", "support_label": "supported", "is_refined": false } ] }, { "id": "multiclinsum_test_339_en.txt", "fulltext": "We present a case of 49 years old Caucasian male suffering from congenital lymphoedema of the left lower extremity who developed composite haemangioendothelioma during his adulthood. Because of the lymphoedema, the patient was first operated on at the age of 6 years, which had only a minor effect on overall condition of the patient. Later on in his life, he experienced multiple erysipelas and at the age of 47 a vascular tumour was detected in the setting of the lymphoedema as its complication. In another institution, a microscopically non-radical (R1) resection was performed and a diagnosis of angiosarcoma was concluded based on the histopathological evaluation of the tumour. The patient was not indicated for any adjuvant therapy, or re-resection. He was followed up and the first control PET/CT scan showed neither local relapse nor distant spread. Local progression was detected after one year of follow up and the patient was re-operated. Second R1 resection was performed and subsequent histopathological examination revealed an angiosarcoma again. This diagnosis was supported by an early second local relapse after a month. After that, the patient was reported to our sarcoma centre for further treatment.\nDuring the clinical investigation, two purple skin affections in the popliteal area at the edges of the dermo-epidermal mesh skin graft were found . The left lower extremity showed chronic disfiguration as a result of multiple erysipelas and chronic lymphoedema. Scattered ecchymoses were also present. In the left gluteal area, multiple small nonspecific purple skin affections were visible. For staging purposes, whole-body PET/MR was performed and revealed multiple small subcutaneous nodules located in the left gluteal area, left calf and left hamstring area . Every nodule demonstrated low metabolic activity; however, the finding raised clinical suspicion for metastases of the previously diagnosed angiosarcoma. During the multidisciplinary tumour board, a bioptic confirmation of the process within gluteal space was indicated. Under local anaesthesia excision biopsy of the skin affection in the gluteal area was performed and sent for histopathological analysis. Within dermis, there was a cavernous vascular tumour (diameter 5 mm) detected, which consisted of dilated thin-walled lymphatic vessels containing papillary protrusions at the periphery. The papillary protrusions contained hyalinised cores in the centre and were covered with columnar endothelial cells with hobnail or even matchstick-like features. There were present neither mitoses nor severe nuclear atypia. Immunohistochemistry (IHC) showed diffuse positivity of the neoplastic cells for CD31, ERG and FLI-1. Tumour showed also focal D2-40 positivity within slit-like spaces at the periphery. IHC markers CD34, HHV-8, CK-KL1 and smooth muscle actin were negative. Based on the clinical background (localization within the dermis of the gluteal area), morphology and immunophenotype of tumorous cells, the suspicion for papillary intralymphatic angioendothelioma (PILA) was raised in contrast to the previous diagnosis . The expected structures of angiosarcoma were not identified within the sample.\nTo evaluate the uncertain undergoing process, the next multidisciplinary meeting led to an indication for excision of the recurrent focus and bioptic evaluation of the nodules of the calf and gluteal area. The operation was performed in February 2022 in form of an excision of two skin affections of the popliteal area (diameter 43 and 78 mm) and another biopsy of the tumour in the calf and gluteal area (diameter 20 mm and 10 mm). Histopathological examinations showed a new finding – the dermal-based vascular tumour with the retiform arrangement was detected, which consisted of branching vascular channels lined with hobnail-shaped bland endothelial cells. At some portions, papillary protrusions with hyalinised cores were found. There were neither mitoses nor nuclear atypia again. On the other hand, no association with the lymphatic vessels was found this time. IHC showed diffuse CD31 positivity and CD34 negativity of the neoplastic cells. Proliferation marker Ki-67 was low with positivity in approximately 10% of the cells within hot spots. Even though the histopathological finding was similar to the previous sample, due to the multifocality of the process, arborizing retiform architecture of the tumour and lacking association with lymphatic vessels in the current biopsy, the diagnosis of retiform haemangioendothelioma was made.\nBecause of the absence of angiosarcomatous structures, the original bioptic material was obtained from the first resection for the second opinion. But, the second look examination confirmed the former diagnosis of HG angiosarcoma: at the border between dermis and sub-cutis there was an infiltration of solid tumour consisting of elongated oval to spindle shaped cells showing marked nuclear atypia and numerous mitoses, including atypical forms. Erythrocytes filled slit-like spaced dissecting the solid areas were detected. IHC showed a similar immune profile of the neoplastic cells (CD31 positive; CD34 and D2-40 negative) and significantly higher proliferation (40–50%) based on the Ki-67 proliferation marker. Such a finding was consistent with the original diagnosis of HG angiosarcoma . However, at the base of the sample, small areas with a morphology of retiform haemangoendothelioma similar to the previous finding were spotted.\nBased on the histopathological findings of three different vascular components resembling PILA, retiform haemangioendothelioma and HG angiosarcoma, the final diagnosis of CHE with HG angiosarcoma-like areas was established.\nRecently it has been discovered that CHE can harbour a fusion gene YAP1::MAML2, especially among children with acral localisation of the tumour . We performed next-generation sequencing (NGS) to investigate this gene fusion and to exclude other entities which could mimic such lesion. Using Fusion Plex Sarcoma V2 panel (Archer) the fusions of the following genes were excluded: ALK, BCOR, BRAF, CAMTA1, CCNB3, CIC, CSF1, EGFR, EPC1, ERG, ESR1, ETV1, ETV4, ETV5, ETV6, EWSR1, FGFR1, FGFR2, FGFR3, FOS, FOSB, FOXO1, FUS, GLI1, HMGA2, JAZF1, MBTD1, MDM2, MEAF6, MET, MGEA5, MKL2, NCOA1, NCOA2, NCOA3, NR4A3, NTRK1, NTRK2, NTRK3, NUTM1, PAX3, PDGFB, PDGFRA, PHF1, PLAG1, PRKCA, PRKCD, RAF1, RET, ROS1, SS18, STAT6, TAF15, TCF12, TFE3, TFG, USP6, VGLL2, YAP1, YWHAE).\nIn conclusion no gene fusion was identified, including YAP1::MAML2. However this finding does not exclude the diagnosis of CHE as for such gene fusion usually does not occur among adult patients outside acral localisations . Moreover, we also examined MYC amplification using fluorescent in situ hybridisation (FISH) as there is an evidence in literature that high-level MYC gene amplifications (at 8q24.21) occur in majority of post-irradiation and chronic lymphoedema-associated angiosarcomas . However MYC amplification was not found in this case, which further supports the diagnosis of CHE favouring it over angiosarcoma.\nEven though CHE usually shows indolent behaviour, the multifocality of the process in the setting of chronic lymphoedema allowed radical surgical treatment, which would have to be hemipelvectomy in this case. Such a procedure was rejected by the patient. Therefore, the current course of action is the follow up with periodical PET/MR scans. In case of local progression of any nodule, the patient would be indicated for the extirpation of the lesion. However, no growth of the remaining lesions was detected in the follow-up so far and there has been no metastatic spread of the disease since the first detection of the tumour two years ago.", "summary": "We present a case of 49 years old male suffering from chronic lymphoedema of the left lower extremity who had developed a composite haemangioendothelioma with high grade angiosarcoma-like areas mimicking the Stewart-Treves syndrome. Given the multifocality of the disease, the only potentially curable surgical treatment would be hemipelvectomy, which was refused by the patient. The patient has been followed-up, with no signs of local progression of the remaining disease, nor a distant spread outside the involved extremity for two years.", "subclaim_evaluations": [ { "subclaim": "The patient is a 49-year-old male.", "support_label": "supported", "is_refined": false }, { "subclaim": "The patient has chronic lymphoedema of the left lower extremity.", "support_label": "supported", "is_refined": false }, { "subclaim": "The patient developed a composite haemangioendothelioma.", "support_label": "supported", "is_refined": false }, { "subclaim": "The haemangioendothelioma had high-grade angiosarcoma-like areas.", "support_label": "supported", "is_refined": false }, { "subclaim": "The lesion mimicked Stewart-Treves syndrome.", "support_label": "supported", "is_refined": false }, { "subclaim": "The disease was multifocal.", "support_label": "supported", "is_refined": false }, { "subclaim": "Hemipelvectomy was considered the only potentially curable surgical treatment.", "support_label": "supported", "is_refined": false }, { "subclaim": "The patient refused hemipelvectomy.", "support_label": "supported", "is_refined": false }, { "subclaim": "The patient was followed up for two years.", "support_label": "supported", "is_refined": false }, { "subclaim": "There were no signs of local progression of the remaining disease.", "support_label": "supported", "is_refined": false }, { "subclaim": "There was no distant spread outside the involved extremity.", "support_label": "supported", "is_refined": false } ] }, { "id": "multiclinsum_test_3374_en.txt", "fulltext": "A 27-year-old black (“Habesha”) lactating woman with gravida 2, para 1, and abortion 1 was referred to our hospital from one of the local health centres with the diagnosis of chronic pelvic pain. Over the previous year, she had multiple visits to different health centers, was repeatedly given medications for acute PID, and was also prescribed different anti-pain medications. Her last delivery was one year ago; it was via cesarean section and uncomplicated. A CU-IUD was provided six weeks after her delivery while she was still breast-feeding. The procedure was followed by abdominal cramps and mild bleeding, which lasted several days.\n\nThree months after insertion, she went to the health center because she could not feel the strings. At that time, a presumptive diagnosis of spontaneous expulsion was made. No further attempts were made to confirm its location. She was also not provided with another family planning during that visit. Upon arrival at our hospital, she complained of dull and aching pain in the lower quadrant of eight-month duration. Otherwise, she has no other complaints. Her vital signs were within the normal range; her BMI (20.5) and CBC parameters were within normal limits. A bimanual examination was performed to reveal a tender 3 cm by 3 cm cul-de-sac mass with no clear distinction from the uterus, and a speculum examination was nonrevealing. Pelvic ultrasound showed an undefined posterior cul-de-sac mass. Futher investigation modalities such as laparoscopy and CT were discussed with the patient, but she could not afford them.\n\nSubsequently, suspecting an intraperitoneal IUD from history and the finding of pelvic mass on ultrasound, the radiologist performed an abdominal erect X-ray with a uterine probe inside in the AP and lateral planes, which both showed that the T-shaped CU-IUD is near and posterior (in the lateral plane) to the uterus.\n\nFinally, a laparotomy was decided and the abdominal cavity was accessed by making a 5-cm incision on a previous transverse skin incision. A careful palpation of the pelvic cavity was performed to determine the specific location, and a string was palpated over the posterior wall of the uterus. On close examination, the IUD was found to be enclosed in a mass formed by the left ovary and the left fallopian tube, which adhered to the posterior wall of the uterus at the junction of the body and the cervix.\n\nConsidering that part of the string was protruding from the mass, the bowel, vessels, and other pelvic structures were examined for perforation, and there was no perforation. Subsequently, after adhesion was removed, the entire IUD (stem, arms, and string) was retrieved from the mass. The uterus was examined and was in a normal anatomic position. Minor surface bleeding from the posterior wall of the uterus and the adnexa was arrested with pressure. After ascertaining hemostasis, the operation was completed. As part of family planning, she was counseled, provided Implanon-NXT, and discharged without complications two days after surgery. Two weeks following the surgery, she stated that her pain had significantly decreased.", "summary": "We discuss the case of a 27-year-old black Ethiopian woman who presented with chronic pelvic pain and had a perforated intrauterine device discovered in the cul-de-sac. The device had been inserted at six weeks postpartum. The client was unable to feel the strings three months after insertion, and a wrong diagnosis of expulsion was made. After one year of insertion, the intrauterine device was located on a plain abdominal radiograph and removed via laparotomy without complications.", "subclaim_evaluations": [ { "subclaim": "The patient is a 27-year-old black Ethiopian woman.", "support_label": "supported", "is_refined": false }, { "subclaim": "She presented with chronic pelvic pain.", "support_label": "supported", "is_refined": false }, { "subclaim": "A perforated intrauterine device was discovered in the cul-de-sac.", "support_label": "not_supported", "original_label": "not_supported", "reasoning_audit": "No explicit tags provided.", "is_refined": true }, { "subclaim": "The intrauterine device had been inserted at six weeks postpartum.", "support_label": "supported", "is_refined": false }, { "subclaim": "The client was unable to feel the strings three months after insertion.", "support_label": "supported", "is_refined": false }, { "subclaim": "A wrong diagnosis of expulsion was made.", "support_label": "supported", "is_refined": false }, { "subclaim": "After one year of insertion, the intrauterine device was located on a plain abdominal radiograph.", "support_label": "supported", "is_refined": false }, { "subclaim": "The intrauterine device was removed via laparotomy.", "support_label": "supported", "is_refined": false }, { "subclaim": "The removal was performed without complications.", "support_label": "supported", "is_refined": false } ] }, { "id": "multiclinsum_test_1313_en.txt", "fulltext": "A 9-year-old boy presented to our clinic with myopia, and he had reported a history of myopic progression that had not been arrested using orthokeratology lenses for 23 months. He had no medical history of glaucoma or pigment dispersion syndrome. On ocular examination, his best-corrected distance visual acuity (BCVA) was 20/20 in both eyes. The refractive power was −1.50 Dsph −0.25 Dcyl Axis 110 in the right eye and −2.00 Dsph −0.25 Dcyl Axis 50 in the left eye. The refractive corneal power was 42.18 D in the right eye and 41.77 D in the left eye. On slit-lamp examination, the cornea and conjunctiva were unremarkable, and there was no evidence of active inflammation in the anterior chamber or neovascularization in the iris. Corneal topography showed slight lateral decentration in both eyes (shown in ). The axial length was 25.39 mm in the right eye and 25.24 mm in the left eye, and the anterior chamber depth was 3.79 mm in the right eye and 3.77 mm in the left eye, as measured by AL-Scan (Nidek Co., Ltd., Gamagori, Japan) (shown in ). The intraocular pressure measured using air-puff non-contact tonometer was 20 mm Hg in the right eye and 21 mm Hg in the left eye. An intraocular pressure of between 10 and 21 mm Hg is defined as the normal range, as reported in previous studies.\nOn ocular examination 2 weeks after the patient discontinued the use of orthokeratology lenses, his refraction was −2.50 Diopter in the right eye and −3.50 Diopter in the left eye, and the best-corrected distance visual acuity was 20/20 in both eyes. We recommended that the patient’s parents refit the orthokeratology lens; however, the parents wanted to keep the orthokeratology lens because of cost considerations. The patient was prescribed topical 0.125% atropine eye drops two times a day in both eyes to prevent myopia progression and maintain the orthokeratology lenses.\nThree days after the treatment, his intraocular pressure rose to 36 mm Hg in the right eye and 32 mm Hg in the left eye, and the best-corrected distance visual acuity was 20/200 in the right eye and 20/100 in the left eye. On slit-lamp examination, the cornea and conjunctiva were unremarkable, and there was no evidence of active inflammation in the anterior chamber. The patient did not use any eye drops or medications, including steroids, did not eat any unusual foods, and did not exhibit any behaviors that increased intraocular pressure, such as Valsalva.\nBecause of the high intraocular pressure, the patient was started on dorzolamide and timolol eye drops twice daily, and 0.125% atropine eye drops and orthokeratology lenses were discontinued. One day later, the intraocular pressure was 26/24 mm Hg, and 2 days later, the intraocular pressure was 21/20 mm Hg. Two months after the discontinuation of all eye drops and orthokeratology lenses, the best-corrected distance visual acuity was 20/20 in both eyes, and the intraocular pressure was 19/20 mm Hg.", "summary": "A 9-year-old boy presented to our clinic with myopia, and he had been wearing orthokeratology lenses overnight for 23 months. He was treated previously with a once-daily administration of topical 0.125% atropine eye drops to reduce myopic progression. Three days after treatment, his intraocular pressure was 36 mm Hg in the right eye and 32 mm Hg in the left eye. Two days after the discontinuation of atropine eye drops and overnight orthokeratology lenses, the intraocular pressure was 18/20 mm Hg in both eyes.", "subclaim_evaluations": [ { "subclaim": "The patient is a 9-year-old boy.", "support_label": "supported", "is_refined": false }, { "subclaim": "The patient presented with myopia.", "support_label": "supported", "is_refined": false }, { "subclaim": "The patient had been wearing orthokeratology lenses overnight.", "support_label": "supported", "is_refined": false }, { "subclaim": "The patient had been wearing orthokeratology lenses for 23 months.", "support_label": "supported", "is_refined": false }, { "subclaim": "The patient was treated with once-daily topical 0.125% atropine eye drops.", "support_label": "not_supported", "original_label": "not_supported", "reasoning_audit": "No explicit tags provided.", "is_refined": true }, { "subclaim": "The treatment with atropine eye drops was intended to reduce myopic progression.", "support_label": "supported", "is_refined": false }, { "subclaim": "Three days after treatment, the intraocular pressure was 36 mm Hg in the right eye.", "support_label": "supported", "is_refined": false }, { "subclaim": "Three days after treatment, the intraocular pressure was 32 mm Hg in the left eye.", "support_label": "supported", "is_refined": false }, { "subclaim": "The atropine eye drops were discontinued.", "support_label": "supported", "is_refined": false }, { "subclaim": "The orthokeratology lenses were discontinued.", "support_label": "supported", "is_refined": false }, { "subclaim": "Two days after discontinuation, the intraocular pressure was 18 mm Hg in the right eye.", "support_label": "not_supported", "original_label": "not_supported", "reasoning_audit": "No explicit tags provided.", "is_refined": true }, { "subclaim": "Two days after discontinuation, the intraocular pressure was 20 mm Hg in the left eye.", "support_label": "supported", "is_refined": false } ] }, { "id": "multiclinsum_test_2880_en.txt", "fulltext": "An 11-month-old female infant presented with bilateral corneal opacity, which was first noted at the age of 3 months. The patient was born full term with an uneventful birth history, and no history of maternal infection or family history of ophthalmologic disease. Ophthalmic examination revealed central corneal opacity approximately 3.0 mm in diameter in the right eye and 2.0 mm in diameter in the left eye, with an underlying keratolenticular adhesion and a cloudy cataract, and that the patient could not trace the light . Contact ultrasound A-scans revealed axial lengths of 18.28 mm and 18.39 mm in the right and left eyes, respectively. Intraocular pressure (IOP) were 14 mmHg in both eyes, measured by a handheld tonometer (Icare Finland Oy Vantaa, Finland). There were no systemic anomalies.\nThe patient’s parents hesitated to accept PKP and fully understood the risks of performing PKP in infants because they had consulted several surgeons before coming to our clinic to seek a second opinion. Her parents were subsequently offered an option of adhesiolysis and adhesive membrane removal combined with lensectomy and vitrectomy. Surgeries were performed at the age of 11 months on 17th and 19th October 2017 in the right and left eye, respectively.\nSurgeries were performed by an experienced surgeon (Y.E.Z.) under general anesthesia using the Accurus with the venturi vacuum system (Alcon Laboratories, Inc.); the cut rate was 2000 per minute and vacuum was 350 mmHg. A corneoscleral incision was made superiorly and four 1.0 mm paracentesis were created in each quadrant. The anterior chamber was initially filled with ophthalmic viscosurgical device (OVD), and the neck of the keratolenticular adhesion was cut using intraocular scissors. There was comprehensive iris posterior synechia. The pupillary aperture was enlarged by four iris hooks through paracentesis in each quadrant after adhesiolysis. Then, a partially resorbed lens and peripheral anterior capsule contraction with zonular elongation were noted underneath the keratolenticular adhesion. The anterior capsular defect was extended to an anterior capsulorhexis of approximately 5.0 mm diameter using a 23-gauge vitrector, while the anterior chamber was maintained by a 23-gauge infusion cannula. After the mode was switched to irrigation/aspiration, the cortex was carefully aspirated. Next, a posterior capsulotomy with a 3.0 mm diameter was performed with the vitrector and the anterior part of the vitreous volume was removed using the same vitrectomy settings. Before the end of the procedure, the residual adhesion was gently peeled off by capsulorhexis forceps curvilinearly following the demarcation line. Surgery was concluded with reformation of the anterior chamber with balanced salt solution and closure of the corneoscleral incision with 10–0 nylon sutures, leaving both eyes aphakic (Additional file 1). No unexpected intraoperative complications were encountered. Clinical manifestations were similar in both eyes.\nTopical treatment consisted of steroidal eye drops gradually tapering over 4 weeks, antibiotic eye drops 4 times daily for 2 weeks, and mydriatic eye drops (phenylephrine hydrochloride and tropicamide compound) once a day for 4 weeks. A gradual reduction in central corneal opacity and improvement in the visual acuity (VA) was noted . Non-contact specular microscopy at one year postoperatively showed large heteromorphic endothelial cells at the borderline between the normal endothelium and the central defect . At the latest follow-up that was two years after surgery, the corneal had excellent transparency, with corrected Teller VA of 20/50 in both eyes and IOP of 15 mmHg in the right eye and 14 mmHg in the left eye. There was no evidence of glaucoma.", "summary": "An 11-month-old female infant of type 2 Peters anomaly presented with bilateral corneal opacity with distinct demarcation, keratolenticular adhesion and cataract, which was first noted at the age of 3 months. By peeling off the adhesion from corneal endothelium combined with lensectomy and vitrectomy, there was a gradual reduction in corneal opacity and improvement in visual acuity after surgery over a 2-year period. Her visual acuity had improved from light perception preoperatively to 20/50 at the latest follow-up. No sight-threatening postoperative complications were noted.", "subclaim_evaluations": [ { "subclaim": "The patient is an 11-month-old female infant.", "support_label": "supported", "is_refined": false }, { "subclaim": "The patient has type 2 Peters anomaly.", "support_label": "supported", "original_label": "not_supported", "reasoning_audit": "No explicit tags provided.", "is_refined": true }, { "subclaim": "The patient had bilateral corneal opacity with distinct demarcation.", "support_label": "supported", "is_refined": false }, { "subclaim": "The patient had keratolenticular adhesion.", "support_label": "supported", "is_refined": false }, { "subclaim": "The patient had cataract.", "support_label": "supported", "is_refined": false }, { "subclaim": "The corneal opacity was first noted at the age of 3 months.", "support_label": "supported", "is_refined": false }, { "subclaim": "The adhesion was peeled off from the corneal endothelium.", "support_label": "supported", "is_refined": false }, { "subclaim": "Lensectomy was performed.", "support_label": "supported", "is_refined": false }, { "subclaim": "Vitrectomy was performed.", "support_label": "supported", "is_refined": false }, { "subclaim": "There was a gradual reduction in corneal opacity after surgery.", "support_label": "supported", "is_refined": false }, { "subclaim": "Visual acuity improved after surgery.", "support_label": "supported", "is_refined": false }, { "subclaim": "The improvement in visual acuity occurred over a 2-year period.", "support_label": "supported", "is_refined": false }, { "subclaim": "Preoperative visual acuity was light perception.", "support_label": "supported", "is_refined": false }, { "subclaim": "The latest follow-up visual acuity was 20/50.", "support_label": "supported", "is_refined": false }, { "subclaim": "No sight-threatening postoperative complications were noted.", "support_label": "supported", "is_refined": false } ] }, { "id": "multiclinsum_test_1305_en.txt", "fulltext": "A 25-year-old gentleman presented to our clinic with a complaint of recurrent pain and swelling on his right cheek of three-month duration. He visited a general practitioner each time, and the condition was resolved with analgesic and antibiotics. However, his symptoms got worse and he attended our Oral Surgery Clinic for consultation.\nThe patient is a fit and healthy young man with no relevant medical history and no known history of allergy. Past surgical history revealed that he had underwent bimaxillary orthognathic surgery one and half year earlier in a local hospital. Although the postoperative period was uneventful, the surgical team informed him that there was a dislodged orthodontic appliance in his right cheek that must have occurred during the operation. The team explained to the patient that this accident was realized later on the next day after the surgery when the molar tube from the right maxillary second molar was found missing, and its presence was confirmed high up in the right maxillary-zygomatic buttress area shown in the postoperative X-ray image taken on the next day following the surgery. A series of further postoperative radiographs confirmed its location, lying outside the right maxillary antrum. Due to the pronounced postoperative facial oedema at that time, no attempt was made to remove the appliance. The absence of sign and symptoms during further follow-up sessions confirmed the decision to leave it in-situ with continuous clinical observation.\nOn examination, there was no extraoral swelling noted. The mandible and maxilla seemed firm indicating good healing following previous mandibular saggital split and maxillary Le Fort I osteotomy sites and a stable class I dental occlusion. Intraorally, there was a sinus with slight pus discharge on the upper right buccal sulcus region adjacent to the upper right first premolar. All teeth in that quadrant were firm and vital. Tenderness was elicited upon palpation on the upper right vestibular region. We suspected the sinus track may originate from the dislodged appliance embedded in the cheek soft tissue. A periapical view was then taken with gutta-percha inserted into the sinus for foreign body localization purpose. The radiograph revealed the gutta-percha pointed towards the site of titanium plate and screws placed used for rigid fixation, and with the molar orthodontic tube appliance in its vicinity . A cone beam CT was performed to provide a 3D detailed location of the appliance and confirmed it to be located outside the maxillary antrum.\nThe presence of the molar orthodontic tube foreign body reaction was suspected as the most probable cause of the recurrent right cheek pain and swelling associated with an intraoral discharging sinus. Exploration of the site was performed through the sulcular incision under general anesthesia. The dislodged molar tube was identified lying on the zygomatic bone just beneath the raised flap. It was removed by dividing some surrounding fibrous tissue strands. Just below it, one titanium straight bone plate with four screws used for fixing the previous Le Fort I osteotomy site was inspected and found to be rigidly embedded in normal bone. However, a decision was made to remove them based on the fact that they are present in an infected area. . The Le Fort I osteotomy site showed good healing with new bone formation. Patient had an uneventful recovery thereafter, and the orthognathic surgical team who attended him previously was informed of his progress.", "summary": "A 25-year-old gentleman presented with recurrent upper right vestibular abscess three months following a bimaxillary orthognathic surgery. A bonded molar orthodontic tube had dislodged into the wound during the operation. The clinical presentation initially mimics an odontogenic infection until our investigations revealed that it originated from the dislodged appliance. The abscess was drained, the wound site was explored, and the molar tube and neighbouring rigid fixation plates and screws were removed. The patient recovered well following the procedure.", "subclaim_evaluations": [ { "subclaim": "The patient is a 25-year-old gentleman.", "support_label": "supported", "is_refined": false }, { "subclaim": "He had a bimaxillary orthognathic surgery.", "support_label": "supported", "is_refined": false }, { "subclaim": "He developed a recurrent upper right vestibular abscess.", "support_label": "supported", "is_refined": false }, { "subclaim": "The abscess occurred three months after the surgery.", "support_label": "supported", "is_refined": false }, { "subclaim": "A bonded molar orthodontic tube had dislodged into the wound during the operation.", "support_label": "supported", "is_refined": false }, { "subclaim": "The clinical presentation initially mimicked an odontogenic infection.", "support_label": "supported", "is_refined": false }, { "subclaim": "Investigations revealed the abscess originated from the dislodged appliance.", "support_label": "supported", "is_refined": false }, { "subclaim": "The abscess was drained.", "support_label": "not_supported", "original_label": "not_supported", "reasoning_audit": "No explicit tags provided.", "is_refined": true }, { "subclaim": "The wound site was explored.", "support_label": "supported", "is_refined": false }, { "subclaim": "The molar tube was removed.", "support_label": "supported", "is_refined": false }, { "subclaim": "Neighbouring rigid fixation plates and screws were removed.", "support_label": "supported", "is_refined": false }, { "subclaim": "The patient recovered well following the procedure.", "support_label": "supported", "is_refined": false } ] }, { "id": "multiclinsum_test_3269_en.txt", "fulltext": "29-year-old female patient with chronic renal disease due to primary focal and segmental glomerulosclerosis, who received a renal transplant in 2017 and was taking tacrolimus, everolimus and prednisone 5 mg daily, was non-diabetic. After a year of progressive deterioration of renal function, diagnosed by gradual increase in serum creatinine and without associated symptoms, a biopsy of the renal graft was performed, which showed findings consistent with pauciimmune vasculitis, so it was decided to hospitalize her to intensify the immunosuppression with methylprednisolone and cyclophosphamide.\n\nThe patient was admitted in a stable condition, afebrile and without urinary symptoms. The examination revealed low inflammatory parameters (C-reactive protein: 17.9 mg/L, white blood cell count: 7,600 cells/uL, absolute neutrophil count: 6,000 cells/uL), but with a urine sediment of 5 leukocytes per field and few bacteria. The urine culture was negative, so 7 urine bacilloscopies were performed, with 3 positive results, reporting 4 to 9 acid-fast bacilli per 100 fields. 6 urine mycobacteria cultures were performed, all negative, as well as a urine sample polymerase chain reaction (PCR) against M. tuberculosis (GeneXpert®) also negative. The study was complemented with a Mycobacterium tuberculosis interferon-gamma release assay (Quantiferon TB-Gold-Plus®) that was negative and a non-contrast computed tomography of the abdomen that did not show structural alterations suggestive of mycobacterial infection.\n\nDue to the context of the patient with an immunosuppression plan, it was decided to postpone the start of immunosuppressive therapy and request the identification of the species of mycobacteria from a urine sample using panmicrobacterial PCR with sequencing of the amplified product. The sequence obtained was compared with the GenBank® database and was compatible with Lawsonella clevelandensis. Following the result, amoxicillin with clavulanic acid 500/125 mg was indicated every 12 h for 3 to 6 months. The patient progressed 4 months later with a severe COVID-19 case, requiring mechanical ventilation and renal replacement therapy, so the antibiotic therapy was extended for 7 months, and the immunosuppressive therapy was restarted after hospital discharge and clinical stabilisation.\n", "summary": "We present the case of a 29-year-old female patient with renal transplant and progressive worsening of renal function in the context of a pauciimmune vasculitis requiring greater immunosuppression. In the laboratory, asymptomatic leukocyturia was noted, with a negative urine culture, so 7 urine bacilloscopies were performed, with positive results in 3, but with PCR of M. tuberculosis and negative mycobacterial culture. Sequencing of the gene that codes for the 16s RNA of the bacterial ribosome was performed from a urine sample, obtaining a sequence compatible with Lawsonella clevelandensis. Following the result, therapy with amoxicillin-clavulanic acid was indicated for 7 months.\n", "subclaim_evaluations": [ { "subclaim": "The patient is a 29-year-old female.", "support_label": "supported", "is_refined": false }, { "subclaim": "The patient has a renal transplant.", "support_label": "supported", "is_refined": false }, { "subclaim": "The patient had progressive worsening of renal function.", "support_label": "supported", "is_refined": false }, { "subclaim": "The patient had pauciimmune vasculitis.", "support_label": "supported", "is_refined": false }, { "subclaim": "The patient required greater immunosuppression.", "support_label": "supported", "is_refined": false }, { "subclaim": "The patient had asymptomatic leukocyturia.", "support_label": "supported", "is_refined": false }, { "subclaim": "The urine culture was negative.", "support_label": "supported", "is_refined": false }, { "subclaim": "Seven urine bacilloscopies were performed.", "support_label": "supported", "is_refined": false }, { "subclaim": "Three urine bacilloscopies were positive.", "support_label": "supported", "is_refined": false }, { "subclaim": "M. tuberculosis PCR was negative.", "support_label": "supported", "is_refined": false }, { "subclaim": "Mycobacterial culture was negative.", "support_label": "supported", "is_refined": false }, { "subclaim": "16s RNA gene sequencing was performed.", "support_label": "not_supported", "original_label": "not_supported", "reasoning_audit": "No explicit tags provided.", "is_refined": true }, { "subclaim": "The sequence was compatible with Lawsonella clevelandensis.", "support_label": "supported", "is_refined": false }, { "subclaim": "The patient received amoxicillin-clavulanic acid.", "support_label": "supported", "is_refined": false }, { "subclaim": "The treatment duration was 7 months.", "support_label": "supported", "is_refined": false } ] }, { "id": "multiclinsum_test_2685_en.txt", "fulltext": "A 30-year-old woman presented with long lasting arthralgia, Raynaud phenomenon, and dyspnoea New York Heart Association (NYHA) Class II. Physical examination at the University Hospital of Brussels revealed cutaneous lesions, a facial butterfly rash and a grade three systolic murmur. Laboratorial investigation revealed an elevated anti-nuclear antibody (ANA) (1:200, normal range ≤1:40 is a negative test, ≥1:160 is a positive test), in the absence of SLE-specific antibodies, reduction of complement factors C3 and C4 (48 mg/dL, normal range 93–177 mg/dL and 6 mg/dl, normal range 14–38 mg/dL, respectively) and severe renal dysfunction (CKD Stage 4, a creatinine of 2.4 mg/dL, normal range 0.4–1.2 mg/dL or an estimated glomerular filtration rate (eGFR) of 24 mL/min/1.73 m2, normal range ≥60 mL/min/1.73 m) with proteinuria. Subsequently, a renal biopsy was performed. A lupus nephritis Class II with mesangioproliferative glomerulonephritis was found. In addition, a skin biopsy confirmed cutaneous involvement.\nTransthoracic echocardiography (TTE) demonstrated a slight restrictive mitral valve motion with minimal thickening of the anterior mitral leaflet-compatible with Libman Sacks (LS) endocarditis, moderate regurgitation (effective regurgitant orifice area 0.19 cm2, regurgitant volume 39 mL), normal left atrial dimension (36 mm, 29.3 mL/m2), and moderate systolic pulmonary hypertension (PHT) of 45 mmHg at rest ( and ).\nSubsequent exercise echocardiography revealed an elevation in systolic pulmonary pressures from 39 to 53 mmHg without increased dyspnoea. Mitral valve (MV) gradients went from a peak and mean of 9/4 mmHg to peak and mean of 22/13 mmHg with a calculated mitral valve area (MVA) of 2.0 cm2. Three-dimensional echocardiography confirmed the severity of the stenotic orifice with a MVA of 3.0 cm2 (see ).\nImmunosuppressive therapy, with cyclophosphamide 500 mg intravenous every 2 weeks and methylprednisolone 64 mg daily for 1 week and afterwards a subsequent progressively decreasing dose, was started. Cyclophosphamide had to be interrupted after two cycles due to recurrent infections. Methylprednisolone 4 mg once a day (q.d.) was continued with clinical improvement (NYHA Class I) and normalization of systolic pulmonary pressure (24 mmHg) after 6 months. After 1 year azathioprine 100 mg q.d. was added to the treatment.\nThe patient was loss to follow-up during a period of 8 years until she presented with complaints of fatigue and progressive exertional dyspnoea NYHA Class III with a grade five systolic murmur and a facial butterfly rash upon clinical examination. Anti-nuclear antibody increased up to 1:1520 with anti-double stranded DNA (anti-dsDNA) 1:20 (normal range ≤1:10 is a negative test). Furthermore, NT-pro-BNP was significantly elevated (10 066 ng/L, normal range 300–450 ng/L). Cardiac re-evaluation with TTE ( and ) demonstrated a more restrictive mitral valve motion with increased and nodular thickening of the anterior leaflet, reduced mitral valve opening with severe mitral valve stenosis (mean gradient of 6.1 mmHg and MVA 1.0 cm2) [0.7 cm2 on three dimensional echo (see )], stable moderate mitral regurgitation, severe left atrial dilatation (48 mm, 59 mL/m2), a normal pericardium and moderate systolic PHT of 40 mmHg at rest. On apical four-chamber view (see ) a ball-like density due to the nodular thickening of the anterior leaflet is appreciated.\nA subsequent exercise echocardiography permitted us to confirm the severity of the disease since gradients are also flow dependent. At 100 W a significant increase of mean MV gradients from 6.1 to 34 mmHg with an increase of systolic PHT from 40 to 67 mmHg and development of severe dyspnoea were appreciated .\nA coronary angiogram with right heart catheterization showed normal coronary arteries and confirmed the moderate PHT of 40 mmHg.\nMethylprednisolone 32 mg twice a day (b.i.d) and cyclophosphamide 500 mg intravenous, every 2 weeks for 3 months, were started in combination with hydroxychloroquine 200 mg b.i.d, bumetadine 2.5 mg q.d, and lisinopril 2.5 mg q.d.\nSubsequently, a mitral valve replacement was performed by a minimally invasive port-access cardiac surgery (mechanical mitral valve St Jude Medical 31 mm). Histopathology of the valve showed fibrosis, neovascularization, inflammatory cell infiltration (plasma cells), and calcification, consistent with valvular involvement of SLE (LS endocarditis) .\nEchocardiography after surgery showed a non-dilatated, normotrophic left ventricle with normal systolic function, mild left atrial dilatation (43 mL/m2), well-functioning mitral valve prosthesis (mean gradient 3.7 mmHg, MVA 1.4–1.5 cm2), and reduced right systolic PHT (23 mmHg).\nOne year later, the clinical condition of the patient was significantly improved with a good exercise capacity and stable SLE under methylprednisolone 4 mg q.d, mycophenolate 500 mg three times a day, and hydroxychloroquine 200 mg b.i.d.", "summary": "A 30-year-old woman with arthralgia, butterfly rash, and Raynaud phenomenon presented with a systolic murmur and renal impairment. Based on the kidney biopsy the diagnosis of SLE was made. Echocardiography revealed the presence of pulmonary hypertension, restrictive mitral valve disease with nodular thickening of the anterior leaflet and moderate regurgitation, compatible with Libman Sacks (LS) endocarditis. Immunosuppressive therapy was started and the patient status improved with normalization of systolic pulmonary artery pressure. After 8 years without follow-up, she presented with fatigue and dyspnoea based on a severe mitral valve stenosis. Subsequently, she underwent a minimal invasive mitral valve replacement and the diagnosis of LS endocarditis could be confirmed upon histopathological examination.", "subclaim_evaluations": [ { "subclaim": "The patient is a 30-year-old woman.", "support_label": "supported", "is_refined": false }, { "subclaim": "She had arthralgia.", "support_label": "supported", "is_refined": false }, { "subclaim": "She had a butterfly rash.", "support_label": "supported", "is_refined": false }, { "subclaim": "She had Raynaud phenomenon.", "support_label": "supported", "is_refined": false }, { "subclaim": "She had a systolic murmur.", "support_label": "supported", "is_refined": false }, { "subclaim": "She had renal impairment.", "support_label": "supported", "is_refined": false }, { "subclaim": "The diagnosis of SLE was made based on the kidney biopsy.", "support_label": "not_supported", "original_label": "not_supported", "reasoning_audit": "No explicit tags provided.", "is_refined": true }, { "subclaim": "Echocardiography revealed pulmonary hypertension.", "support_label": "supported", "is_refined": false }, { "subclaim": "Echocardiography showed restrictive mitral valve disease.", "support_label": "supported", "is_refined": false }, { "subclaim": "The anterior leaflet had nodular thickening.", "support_label": "supported", "is_refined": false }, { "subclaim": "There was moderate mitral regurgitation.", "support_label": "supported", "is_refined": false }, { "subclaim": "The findings were compatible with Libman Sacks endocarditis.", "support_label": "supported", "is_refined": false }, { "subclaim": "Immunosuppressive therapy was started.", "support_label": "supported", "is_refined": false }, { "subclaim": "The patient's status improved.", "support_label": "supported", "is_refined": false }, { "subclaim": "Systolic pulmonary artery pressure normalized.", "support_label": "supported", "is_refined": false }, { "subclaim": "After 8 years without follow-up, she presented with fatigue.", "support_label": "supported", "is_refined": false }, { "subclaim": "After 8 years without follow-up, she presented with dyspnoea.", "support_label": "supported", "is_refined": false }, { "subclaim": "The cause was severe mitral valve stenosis.", "support_label": "supported", "is_refined": false }, { "subclaim": "She underwent a minimal invasive mitral valve replacement.", "support_label": "supported", "is_refined": false }, { "subclaim": "The diagnosis of Libman Sacks endocarditis was confirmed on histopathological examination.", "support_label": "supported", "is_refined": false } ] }, { "id": "multiclinsum_test_1652_en.txt", "fulltext": "A healthy 10-year-old male patient presented to the Department of Pediatric and Preventive Dentistry, M.S. Ramaiah Faculty of Dental Sciences, Bengaluru, Karnataka, India, for routine dental care. Oral examination revealed mixed dentition, with deficient space for eruption of second premolar teeth ( and ). The treatment planned was distalization of maxillary first permanent molars by intra-arch pendulum appliance developed by Hilgers. Both the maxillary first permanent molars and first premolars were banded and impression of maxillary arch was made. The pendulum appliance design consisted of anterior acrylic nance portion with two posteriorly extending TMA coil springs made of 0.032\". The plane of the coil springs should be parallel to the maxillary plane; the extensions of TMA wire are then soldered to the molar and premolar bands . The appliance was cemented onto the molars and premolars. The appliance was activated extraorally and was cemented. The appliance was monitored at monthly intervals and the appliance was removed for reactivation and recementation.\nAt the end of 4th month sufficient space was regained and second premolars started erupting into the space gained. At 7th month with the complete eruption of premolars and canines proper maxillary arch alignment was achieved ( and ). The results of this case study have shown that the pendulum appliance is an effective and reliable method for distalization of maxillary molar teeth.", "summary": "The purpose of this paper is to report a case of 10-year-old male patient with loss of space in maxillary molar teeth treated by intra-arch appliance-pendulum appliance by distalization of maxillary first permanent molar teeth. Distaliza-tion of the permanent molar teeth helped in proper eruption of second premolar teeth without any extensive treatment procedures.", "subclaim_evaluations": [ { "subclaim": "The patient is a 10-year-old male.", "support_label": "supported", "is_refined": false }, { "subclaim": "The patient had loss of space in maxillary molar teeth.", "support_label": "supported", "is_refined": false }, { "subclaim": "The treatment involved an intra-arch appliance.", "support_label": "supported", "is_refined": false }, { "subclaim": "The appliance used was a pendulum appliance.", "support_label": "supported", "is_refined": false }, { "subclaim": "The treatment involved distalization of maxillary first permanent molar teeth.", "support_label": "supported", "is_refined": false }, { "subclaim": "Distalization helped in the proper eruption of second premolar teeth.", "support_label": "supported", "is_refined": false }, { "subclaim": "The treatment did not require extensive procedures.", "support_label": "supported", "is_refined": false } ] }, { "id": "multiclinsum_test_2444_en.txt", "fulltext": "On 24 January 2020, a 48-year-old male patient with a history of asthma was transferred to our department due to acute myocarditis of unknown origin. The patient described a sudden onset of high-grade fever without prodromal symptoms beginning on 12 January. Within a few days, he developed dyspnoea and haemoptysis requiring hospital admission.\nLaboratory testing showed high levels of the inflammatory markers creatine phosphokinase (CPK) and lactate dehydrogenase (LDH; see ). Ferritin was only marginally elevated. His differential blood count showed prominent eosinophilia (19%) and lymphopenia (18%). Testing for autoantibodies only yielded antinuclear antibodies (ANAs) at a very low titre without any detectable specificity against a broad panel of nuclear antigens. However, myositis-associated antibodies, antineutrophilic cytoplasmic antibodies (ANCAs), as well as antiphospholipid antibodies were negative. The measurement of vital signs revealed tachycardia (100 b.p.m.) with hypotonic blood pressure (90/65 mmHg) and fever (39°C). On physical examination, lower leg oedema was present. The auscultation of heart and lungs was unremarkable.\nThoracic computed tomography (CT) showed bilateral, patchy peripheral ground-glass opacities with a crazy-paving pattern, focal consolidations, and mild pleural effusions . Due to highly elevated cardiac markers [N-terminal probrain natriuretic peptide (NT-proBNP) and troponin T], echocardiography and cardiac magnetic resonance imaging (MRI) were performed. Both showed highly reduced ventricular function [left ventricular ejection fraction (LVEF) 22%, right ventricular ejection fraction (RVEF) 28%]. Furthermore, late gadolinium enhancement (LGE) of the entire left ventricular myocardium with intracardial thrombi was detected on MRI . T1 and T2 times were markedly prolonged, reflecting acute oedema following myocardial inflammation. In light of a multifaceted differential diagnosis, pulmonary and myocardial biopsies were performed. Histopathological analysis of the pulmonary biopsy showed interstitial alveolitis with capillaritis, necrosis, and mild eosinophilia. The cardiac specimen revealed active lymphocytic myocarditis . PCR analysis for usual cardiotropic viruses was negative. A few days after admission, the patient developed an acute renal injury with microhaematuria.\nBased on these findings and the clinical presentation at that point, the diagnosis of an ANCA-negative small-vessel vasculitis was established. Given the known asthma, eosinophilia, renal injury with microhaematuria, and cardiopulmonary inflammation, the patient fulfilled the criteria for eosinophilic granulomatosis with polyangiitis (EGPA) despite the lack of ANCAs.\nIn accordance with current guidelines, pulse therapy with cyclophosphamide and high-dose steroids was initiated, and the patient recovered adequately after several weeks of treatment. On discharge, the patient was afebrile without dyspnoea, but a wearable defibrilator was prescribed. .\nAfter discharge of the patient from our hospital, the COVID-19 pandemic had evolved to affect Europe as well. Individual cases were reported at the end of January and early February in France, Italy, and Austria. Owing to the initial broad spectrum of differential diagnoses, we revisited the complete medical history and contacted the patient, who reported a prior vacation in Tyrol, Austria, from which the patient and his family had returned 1 day before the sudden onset of his symptoms. It is of interest that Austria is considered the origin of the COVID-19 outbreak in Europe. The distance from Tyrol to our department in Germany is ∼500 km. One week later, the patient arrived at the hospital because of a progressive fever and weakness. Moreover, the patient reported that his 8-year-old daughter developed flu-like symptoms with a high-grade fever (40.7°C/105°F) ∼1 week after his first symptoms.\nSubsequently, PCR testing for SARS-CoV-2 RNA was initiated on the histological specimens of the heart using quantitative reverse transcription–PCR (RT–qPCR) kits targeting the E gene and RdRp gene (TIB MOLBIOL, Roche Diagnostics, Germany), and the N2 assay (N gene). Unexpectedly, those tests were positive for SARS-CoV-2 RNA. Therefore, we revised the diagnosis from small-vessel vasculitis to COVID-19-associated myocarditis and immediately stopped immunosuppressive treatment with cyclophosphamide. The steroid dose was also tapered. The course of resolving the intracardial thrombus was accomplished with a therapy that included coumarin-type drugs. The normalization of elevated laboratory inflammation markers, improvement of cardiac function on echocardiography, and the absence of cardiac inflammation on cardiac MRI confirmed the patient’s recovery.\nThe pulmonary specimen showed mild eosinophilia with parenchymal necrosis and alveolitis. Staining for CD31, factor VIII, and CD68 were positive, while all other staining experiments were negative. In the cardiac specimen, markedly elevated counts of lymphocytes (positive for LFA-1, CD45R0, and CD3) and elevated counts of macrophages (positive for MAC-1) could be detected along with the expression of adhesion molecules (ICAM-1). In contrast, perforin-expressing cytotoxic cells were not present. While PCR did not detect typical cardiotropic viruses, additional testing for SARS-CoV-2 RNA revealed a positive signal in the myocardium.", "summary": "A 48-year-old male patient presented with fever, dyspnoea, and haemoptysis. Laboratory findings showed highly elevated inflammatory and cardiac damage markers. Thoracic computed tomography (CT) revealed bilateral, patchy peripheral ground-glass opacities with a crazy-paving pattern, focal consolidations, and mild pleural effusions. Cardiac imaging with echocardiography and magnetic resonance imaging (MRI) detected a reduced biventricular function. MRI additionally showed myocardial oedema and late gadolinium enhancement. Lung and heart biopsies were performed, revealing alveolitis with necrosis and acute lymphocytic myocarditis. Testing for usual cardiotropic viruses was negative, and no aspects of vasculitis or granuloma could be found. Due to fulfilling the criteria, the patient was diagnosed with rheumatic vasculitis. Treatment with cyclophosphamide and steroids was initiated. Later, the patient reported a history of travel to Tyrol in mid January. Consequently, PCR testing for SARS-CoV-2 was performed, which was positive in the heart specimen. Immunosuppressive treatment was discontinued. During a follow-up visit at the end of April, the patient's recovery was stable.", "subclaim_evaluations": [ { "subclaim": "The patient is a 48-year-old male.", "support_label": "supported", "is_refined": false }, { "subclaim": "The patient presented with fever.", "support_label": "supported", "is_refined": false }, { "subclaim": "The patient presented with dyspnoea.", "support_label": "supported", "is_refined": false }, { "subclaim": "The patient presented with haemoptysis.", "support_label": "supported", "is_refined": false }, { "subclaim": "Thoracic CT revealed bilateral, patchy peripheral ground-glass opacities.", "support_label": "supported", "is_refined": false }, { "subclaim": "Thoracic CT showed a crazy-paving pattern.", "support_label": "supported", "is_refined": false }, { "subclaim": "Thoracic CT showed focal consolidations.", "support_label": "supported", "is_refined": false }, { "subclaim": "Thoracic CT showed mild pleural effusions.", "support_label": "supported", "is_refined": false }, { "subclaim": "Cardiac imaging detected reduced biventricular function.", "support_label": "supported", "is_refined": false }, { "subclaim": "MRI showed myocardial oedema.", "support_label": "supported", "is_refined": false }, { "subclaim": "MRI showed late gadolinium enhancement.", "support_label": "supported", "is_refined": false }, { "subclaim": "Lung biopsies revealed alveolitis with necrosis.", "support_label": "supported", "is_refined": false }, { "subclaim": "Heart biopsies revealed acute lymphocytic myocarditis.", "support_label": "supported", "is_refined": false }, { "subclaim": "Testing for usual cardiotropic viruses was negative.", "support_label": "supported", "is_refined": false }, { "subclaim": "No aspects of vasculitis were found.", "support_label": "not_supported", "original_label": "not_supported", "reasoning_audit": "No explicit tags provided.", "is_refined": true }, { "subclaim": "The patient was diagnosed with rheumatic vasculitis.", "support_label": "not_supported", "original_label": "not_supported", "reasoning_audit": "No explicit tags provided.", "is_refined": true }, { "subclaim": "Treatment with cyclophosphamide and steroids was initiated.", "support_label": "supported", "is_refined": false }, { "subclaim": "The patient reported a history of travel to Tyrol in mid January.", "support_label": "supported", "is_refined": false }, { "subclaim": "PCR testing for SARS-CoV-2 was performed.", "support_label": "supported", "is_refined": false }, { "subclaim": "PCR testing for SARS-CoV-2 was positive in the heart specimen.", "support_label": "supported", "is_refined": false }, { "subclaim": "Immunosuppressive treatment was discontinued.", "support_label": "supported", "is_refined": false }, { "subclaim": "During a follow-up visit at the end of April, the patient's recovery was stable.", "support_label": "not_supported", "original_label": "not_supported", "reasoning_audit": "No explicit tags provided.", "is_refined": true } ] }, { "id": "multiclinsum_test_2082_en.txt", "fulltext": "The patient was a 49-year-old man from Shanxi province who was born to non-consanguineous parents. He presented with a history of progressive shortness of breath and edema of both lower limbs for 7 days. One week before admission, the patient developed shortness of breath in a supine position at night, which improved after 3-5 minutes of rest in the sitting position. The shortness of breath recurred 3–4 times per night, accompanied by progressive edema of both lower extremities. The patient denied any history of hypertension, diabetes, or smoking. Starting from the age of 8 years, the patient showed signs of bilateral upper and lower limb weakness during exercise and his sports tests never met the standard. At the age of 35 years, he started to complain of difficulty in swallowing solid food. Mild bilateral ptosis was noticed from the age of 45 years. He had a family history of MM. His eldest sister was diagnosed with MM based on histochemical analysis of skeletal muscle biopsy. However, no records of the exact site of mutation in the eldest sister were available. She developed respiratory failure at the age of 52 years and died of respiratory failure several years ago. The second sister showed progressive ptosis and bilateral limb weakness; however, she has not yet undergone skeletal muscle biopsy. The parents and the little sister of the patient appear in good health at present. The pedigree map of three generations of the family is shown in Fig. . The patient in our report is the family member, II-3.\nThe patient had acute symptoms, but had normal sensorium at the time of hospitalization. He looked very thin and his height was 1.83 meters and weight was 49 kg. His vital signs were: body temperature, 36.6°C; pulse rate, 89 beats/min; respiratory rate, 25 beats/min; blood pressure, 124/85 mmHg. There was ptosis and facial weakness. Chest percussion showed dullness on the right chest wall and no significant enlargement of the heart; no cardiac murmur was heard on auscultation. Neurological examination showed no cranial nerve deficit. His cognitive abilities were normal. Ptosis was mild on the right and moderate on the left side. At rest, muscle strength and tone were normal in all 4 limbs. Serum creatine kinase (CK) level was 2280 IU/L (normal value < 200) while liver enzyme levels were slightly increased, including aspartate aminotransferase (AST) (120 IU/L; normal value <40 IU/L) and alanine aminotransferase (ALT) (57 IU/L; normal value <40 IU/L). Serum antinuclear autoantibodies/extractable nuclear antigens (ANA/ENA) levels were normal. Electrocardiogram and D-dimer level were normal. The B-type natriuretic peptide (BNP) level was 606 pg/mL and the level of soluble growth stimulating gene protein (sST2) was 97.64 ng/mL (normal value <35 ng/ml). Findings of arterial blood gas (ABG) analysis were: pH 7.286; PaCO2 73.6 mmHg; PaO2 62.7 mmHg; lactate 2.82 mmol/L (normal value <2.2 mmol/L); hemoglobin 177g/L. Although the PaO2 level was within the normal range on low-flow oxygen inhalation, the diagnosis of type II respiratory failure was considered because of hypercapnia. Pulmonary function test suggested severe restrictive ventilatory impairment. Chest high resolution CT showed bilateral pleural effusion (more on the right side) and increased thickness of pulmonary artery trunk and branches. The patient showed none of emboli, mosaic perfusion, disparity in segmental vessel size, parenchymal densities and thickening of bilateral pulmonary arteries in Computed tomographic pulmonary angiography (CTPA). Echocardiography revealed right heart overload characterized by dilated right ventricle (RV diastolic dimension: 44 mm) and right atrium (RA dimension: 45 mm) . Color Doppler ultrasound revealed mild tricuspid regurgitation and mild to moderate pulmonary hypertension; the systolic pulmonary arterial pressure was 56 mmHg. The tricuspid annular plane systolic excursion (TAPSE) level was 22 mm. Echocardiography showed normal left ventricular chamber volume with normal systolic function (estimated ejection fraction 71%) and normal filling pressures. Left ventricle short-axial view showed symmetric slight thickening of the left ventricle (LV) and the LV mass indexed for BSA was 118.07g/m2. At the end diastolic phase of the left ventricle, the thickness of both the ventricular septum and the posterior left ventricular wall is 13 mm.\nNeedle electromyography (EMG) examination showed rapid recruitment of short-duration, low-amplitude motor unit potentials (MUPs) in bilateral deltoid muscles. He underwent muscle biopsy of left lateral thigh, which revealed variable size and shape of muscle fibers, with coexistence of oblong or small round fibers, occasional necrosis or regeneration of muscle fibers, hypertrophic fibers and split fibers in addition to typical features of mitochondrial dysfunction, including 8% ragged red fibers (RRF) and 42% COX-negative fibers.\nGene sequencing analysis conducted by BGI Clinical Laboratory Center (Shenzhen, China) revealed a novel TK2 mutation at c.584T>C. The predicted amino acid change was p. Leu195 Pro. Whole exon gene results of the proband and family members showed that the mother had wild-type and the father, sister, and the patient had heterozygote TK2 variant (NM_001172644: c.584T>C, p.Leu195Pro). In-depth analysis revealed a heterozygous variant in an intron of TK2 (NM_004614.4:c.156+958G>A; rs1965661603) in the mother of the proband, the sister, and the proband. Based on the findings of muscle biopsy and DNA sequencing, the patient was diagnosed as a case of MM .\nHe was administered intravenous diuretic and recombinant human brain natriuretic peptide. Round-the-clock non-invasive ventilation was provided during the first 10 days of hospitalization; subsequently, artificial ventilation was provided only at night. The shortness of breath was significantly alleviated with complete resolution of bilateral lower limb edema. ABG analysis results prior to discharge were: pH 7.388; PaCO2 52.7 mmHg; PaO2 123.5 mmHg; and hemoglobin 155 g/L. The patient was prescribed with the nocturnal non-invasive ventilation and coenzyme Q10 (CoQ10) at discharge. CoQ10 can promote oxidative phosphorylation and protect the integrity of biological cell membrane, it increases adenosine triphosphate (ATP) generation and cellular energy by mediating electron transfer in the electron transport chain. CoQ10 can be used as an adjunctive therapy for mitochondrial myopathy or heart failure. Echocardiography performed after one month showed no obvious abnormalities in cardiac structure or function. Echocardiography findings also showed improvement after treatment . No abnormalities were observed in BNP and sST2 levels. CK was reduced to 1250 IU/L and liver enzyme levels were restored to normal. ABG parameters were within the normal range (pH 7.411; PaCO2 42.9 mmHg; PaO2 86.5 mmHg; lactate 2.0 mmol/L; hemoglobin 151 g/L). A one-year follow-up, the patient was found to have well tolerated non-invasive ventilation support. He was able to perform his routine activities with no restrictions. Echocardiography showed normal cardiac structure and function. Currently, nocturnal bilevel positive airway pressure (BiPAP) therapy via a basal mask had been well-tolerated and ABG analysis was performed every 1 month, the ventilation pattern had not been changed after discharge. The patient is regularly receiving CoQ10.", "summary": "A 49-year-old man presented with clinical features suggestive of MM, i.e., ophthalmoparesis, weakness of the pharyngeal and extremity muscles, and respiratory muscles which gradually progressed to respiratory insufficiency. He had a family history of mitochondrial myopathy. He had increased levels of serum creatine kinase and lactate. Muscle biopsy of left lateral thigh revealed 8% ragged red fibers (RRF) and 42% COX-negative fibers. Gene sequencing revealed a novel heterozygote TK2 variant (NM_001172644: c.584T>C, p.Leu195Pro) and another heterozygous variant (NM_004614.4:c.156+958G>A; rs1965661603) in the intron of TK2 gene. Based on these findings, we diagnosed the patient as a case of MM. Echocardiography revealed right heart enlargement, pulmonary hypertension, left ventricular hypertrophy, and thickening of the main pulmonary artery and its branches. The patient received non-invasive ventilation and coenzyme Q10 (CoQ10). The cardiac structure and function were restored at 1-month follow-up.", "subclaim_evaluations": [ { "subclaim": "The patient is a 49-year-old man.", "support_label": "supported", "is_refined": false }, { "subclaim": "The patient had ophthalmoparesis.", "support_label": "not_supported", "original_label": "not_supported", "reasoning_audit": "No explicit tags provided.", "is_refined": true }, { "subclaim": "The patient had weakness of the pharyngeal muscles.", "support_label": "supported", "is_refined": false }, { "subclaim": "The patient had weakness of the extremity muscles.", "support_label": "supported", "is_refined": false }, { "subclaim": "The patient had weakness of the respiratory muscles.", "support_label": "supported", "is_refined": false }, { "subclaim": "The patient's respiratory muscle weakness progressed to respiratory insufficiency.", "support_label": "supported", "is_refined": false }, { "subclaim": "The patient had a family history of mitochondrial myopathy.", "support_label": "supported", "is_refined": false }, { "subclaim": "The patient had increased serum creatine kinase.", "support_label": "supported", "is_refined": false }, { "subclaim": "The patient had increased serum lactate.", "support_label": "supported", "is_refined": false }, { "subclaim": "Muscle biopsy of the left lateral thigh showed 8% ragged red fibers.", "support_label": "supported", "is_refined": false }, { "subclaim": "Muscle biopsy of the left lateral thigh showed 42% COX-negative fibers.", "support_label": "supported", "is_refined": false }, { "subclaim": "Gene sequencing revealed a novel heterozygous TK2 variant (NM_001172644: c.584T>C, p.Leu195Pro).", "support_label": "supported", "is_refined": false }, { "subclaim": "Gene sequencing revealed another heterozygous variant (NM_004614.4:c.156+958G>A; rs1965661603) in the intron of the TK2 gene.", "support_label": "supported", "is_refined": false }, { "subclaim": "The patient was diagnosed with mitochondrial myopathy.", "support_label": "supported", "is_refined": false }, { "subclaim": "Echocardiography showed right heart enlargement.", "support_label": "supported", "is_refined": false }, { "subclaim": "Echocardiography showed pulmonary hypertension.", "support_label": "supported", "is_refined": false }, { "subclaim": "Echocardiography showed left ventricular hypertrophy.", "support_label": "supported", "is_refined": false }, { "subclaim": "Echocardiography showed thickening of the main pulmonary artery and its branches.", "support_label": "supported", "is_refined": false }, { "subclaim": "The patient received non-invasive ventilation.", "support_label": "supported", "is_refined": false }, { "subclaim": "The patient received coenzyme Q10.", "support_label": "supported", "is_refined": false }, { "subclaim": "At 1-month follow-up, the cardiac structure and function were restored.", "support_label": "supported", "is_refined": false } ] }, { "id": "multiclinsum_test_1603_en.txt", "fulltext": "A 57-year-old Caucasian woman reported a decrease in visual acuity for 2 weeks. Her best-corrected visual acuity for her right eye was 20/20 and for her left eye 20/100. A slit-lamp examination and intraocular pressure were unremarkable in both eyes. Fundus examination of her left eye revealed temporal intraretinal infiltrates and vitreous opacities . Her right eye was unremarkable.\nFluorescein angiography showed hyperfluorescence of her optic disc, leakage along the vessels, and chorioretinal hyperfluorescent infiltrates . The diagnosis of OT was based on the typical morphology of her ocular lesions and a positive serological testing for Toxoplasma gondii (immunoglobulin G concentration = 537IU/mL).\nShe was treated with clindamycin (Clindamycin® H) 4 × 300mg daily over 3 days without any significant improvement of visual acuity. On the fourth day of hospitalization, she received 100mg prednisolone-21-hydrogensuccinate (Solu-Decortin® H) intravenously in addition to her treatment with clindamycin (Clindamycin® H). Within 2 minutes she developed an acute erythema, particularly of her legs and abdomen , angioedema, hypotension (blood pressure 80/40mmHg), tachycardia (heart rate 140/minute), hyperthermia (38.8°C), and respiratory distress. Subsequently, she was transferred to the Intensive Care Unit to be monitored and treated with clemastine fumarate (Tavegil®), ranitidin (Ranitic®), and intravenous fluids. After 1 hour she recovered and after 12 hours she was transferred back to the ophthalmological ward. Her erythema and angioedema persisted for 32 hours. She had no history of previous steroid use. Subsequent allergy testing was conducted after 3 months in the Department of Dermatology in our hospital. The testing showed a positive skin-prick test for prednisolone and methylprednisolone in the form of a 5mm wheal, and negative results for dexamethasone and hydrocortisone , which confirmed her suspected allergy to prednisolone. Because of her allergic reaction to class A (prednisone-type) corticosteroids and possible complications due to cross-reactions to class D2 (prednicarbate-type) corticosteroids, we avoided any further treatment with systemic or intravitreal corticosteroids.\nIn addition, an oral exposure test with a step-by-step elevation of doses up to 2.0mg of dexamethasone (Fortecortin®) and 1.5mg betamethasone (Celestamine®) was conducted to find alternative corticosteroids for future treatments. For both substances, no local or systemic side effects were observed.\nAfter 1 month of treatment with clindamycin (Clindamycin® H) monotherapy without any increase in visual acuity, the patient underwent a vitrectomy with balanced salt solution filling because of heavy vitreous opacities, and to obtain a sample of the vitreous body. The polymerase chain reaction (PCR) on the sample was positive for Toxoplasma gondii.\nThe postoperative examination of her left eye revealed chorioretinal scars and infiltrates . Her right eye was still unremarkable. Fluorescein angiography of her left eye also revealed hyperfluorescent intraretinal infiltrates of the temporal hemisphere and a scar of the inferotemporal retinal vein branch . Her visual acuity recovered to right eye 20/20 and left eye 20/40.", "summary": "We present the case of a 57-year-old Caucasian woman with an anaphylactic reaction after intravenous injection of prednisolone-21-hydrogensuccinate (Solu-Decortin® H) given for the treatment of toxoplasmosis-associated chorioretinitis. Immediately after the injection, she developed an acute erythema of the legs and abdomen, angioedema, hypotension (blood pressure 80/40mmHg), tachycardia (heart rate 140/minute), hyperthermia (38.8°C), and respiratory distress. Allergological examinations showed a positive skin-prick test to prednisolone and methylprednisolone. In addition, an oral exposure test with dexamethasone (Fortecortin®) and betamethasone (Celestamine®) was conducted to find alternative corticosteroids for future treatments. After oral application, no local or systemic reactions were observed for these two substances.", "subclaim_evaluations": [ { "subclaim": "The patient is a 57-year-old woman.", "support_label": "supported", "is_refined": false }, { "subclaim": "The patient is Caucasian.", "support_label": "supported", "is_refined": false }, { "subclaim": "The patient had an anaphylactic reaction.", "support_label": "supported", "is_refined": false }, { "subclaim": "The anaphylactic reaction occurred after intravenous injection of prednisolone-21-hydrogensuccinate.", "support_label": "supported", "is_refined": false }, { "subclaim": "The prednisolone-21-hydrogensuccinate was given for the treatment of toxoplasmosis-associated chorioretinitis.", "support_label": "supported", "is_refined": false }, { "subclaim": "The patient developed an acute erythema of the legs and abdomen.", "support_label": "supported", "is_refined": false }, { "subclaim": "The patient developed angioedema.", "support_label": "supported", "is_refined": false }, { "subclaim": "The patient had hypotension with a blood pressure of 80/40mmHg.", "support_label": "supported", "is_refined": false }, { "subclaim": "The patient had tachycardia with a heart rate of 140/minute.", "support_label": "supported", "is_refined": false }, { "subclaim": "The patient had hyperthermia with a temperature of 38.8°C.", "support_label": "supported", "is_refined": false }, { "subclaim": "The patient had respiratory distress.", "support_label": "supported", "is_refined": false }, { "subclaim": "Allergological examinations showed a positive skin-prick test to prednisolone.", "support_label": "supported", "is_refined": false }, { "subclaim": "Allergological examinations showed a positive skin-prick test to methylprednisolone.", "support_label": "supported", "is_refined": false }, { "subclaim": "An oral exposure test with dexamethasone was conducted.", "support_label": "supported", "is_refined": false }, { "subclaim": "An oral exposure test with betamethasone was conducted.", "support_label": "supported", "is_refined": false }, { "subclaim": "No local or systemic reactions were observed after oral application of dexamethasone.", "support_label": "supported", "is_refined": false }, { "subclaim": "No local or systemic reactions were observed after oral application of betamethasone.", "support_label": "supported", "is_refined": false } ] }, { "id": "multiclinsum_test_810_en.txt", "fulltext": "A 15-year-old female, the eldest sibling of patient 1, was diagnosed with\ntyrosinemia type III at eight years of age, after a family screening\nfollowing her brother’s diagnosis.\nShe was born at term by cesarean section (pelvic presentation) following an\nuneventful pregnancy, with an Apgar score of 8 and 9 at 1 and 5 minutes,\nrespectively. Her birth weight was 4,030 g (87th percentile),\nlength 53 cm (87th percentile), and head circumference 36 cm\n(83rd percentile). Her neonatal period was unremarkable, as\nwas her early psychomotor development. She had a history of primary\nnocturnal enuresis and vesical instability, treated with desmopressin and\noxybutynin hydrochloride since the age of six.\nShe was diagnosed with ADHD at the age of five and treated with\nmethylphenidate and risperidone. She presented learning difficulties when\nshe attended elementary school (2nd grade), and was included in a\nspecial education program at the age of ten.\nAt the time of diagnosis, her initial tyrosine level was 1,769 µmol/L. On the\nfirst nutritional status evaluation, her daily natural protein intake was\n1.4 g/kg. This value dropped to 1.08 g/kg, and she started taking\nsupplementation with 0.7 g of amino acids/kg from phenylalanine- and\ntyrosine-free amino acid mixtures, enabling a consistent decrease of\ntyrosine levels below 300 µmol/L.\nHer physical examination and growth were normal (weight and height at the\n50‒85th percentile), with an unremarkable neurological\nexamination. The genetic study revealed the same mutation as her brother in\nhomozygosity.\nAfter initiating a low-protein diet, her behavior and school performance did\nnot improve. The minimum level of daily natural protein intake reached was\n0.65 g/kg at 14 years of age. She is currently in 7th grade,\nstill in the special education program, and under treatment with\nmethylphenidate. Her latest formal developmental assessment (Wechsler\nIntelligence Scale for Children®, third edition, Portuguese\nversion) revealed a global IQ score of 68, with a verbal IQ of 68 and a\nperformance IQ of 77 .\nShe slowly began diet liberalization and is now with a daily natural protein\nintake of 0.9 g/kg, combined with 0.8 g of amino acids/kg, maintaining\ntyrosine levels below 300 µmol/L nevertheless.", "summary": "The index case was diagnosed by newborn screening for endocrine and metabolic disorders, starting a low-protein diet immediately, with a consistent decrease in tyrosine levels. By the age of three, the child displayed a hyperactive behavior, starting treatment for ADHD two years later. At seven years of age, he shows a slight improvement in terms of behavior and attention span and has a cognitive performance slightly lower than his peers, despite maintaining acceptable tyrosine levels. His sister, who had a history of ADHD since age five, was diagnosed with HT III after family screening at the age of eight. Despite initiating a dietetic treatment, her behavior did not improve, and she has a mild intellectual impairment.", "subclaim_evaluations": [ { "subclaim": "The index case was diagnosed by newborn screening for endocrine and metabolic disorders.", "support_label": "not_supported", "original_label": "not_supported", "reasoning_audit": "No explicit tags provided.", "is_refined": true }, { "subclaim": "A low-protein diet was started immediately.", "support_label": "supported", "is_refined": false }, { "subclaim": "Tyrosine levels consistently decreased.", "support_label": "supported", "is_refined": false }, { "subclaim": "By the age of three, the child displayed hyperactive behavior.", "support_label": "supported", "is_refined": false }, { "subclaim": "Treatment for ADHD started two years after the age of three.", "support_label": "supported", "is_refined": false }, { "subclaim": "At seven years of age, the child showed slight improvement in behavior and attention span.", "support_label": "not_supported", "original_label": "not_supported", "reasoning_audit": "No explicit tags provided.", "is_refined": true }, { "subclaim": "The child's cognitive performance is slightly lower than his peers.", "support_label": "supported", "is_refined": false }, { "subclaim": "The child has acceptable tyrosine levels.", "support_label": "supported", "is_refined": false }, { "subclaim": "The child's sister had a history of ADHD since age five.", "support_label": "supported", "is_refined": false }, { "subclaim": "The sister was diagnosed with HT III after family screening at the age of eight.", "support_label": "supported", "is_refined": false }, { "subclaim": "Dietetic treatment was initiated for the sister.", "support_label": "supported", "is_refined": false }, { "subclaim": "The sister's behavior did not improve.", "support_label": "supported", "is_refined": false }, { "subclaim": "The sister has mild intellectual impairment.", "support_label": "supported", "is_refined": false } ] }, { "id": "multiclinsum_test_953_en.txt", "fulltext": "A 54-year-old white man with a past medical history of right maxillary sinus adenoid cystic carcinoma with metastatic lesions to lung and vertebrae, hypertension, hypothyroidism, and nonalcoholic steatohepatitis presented to our emergency room in June 2016 with mental status changes accompanied by abdominal pain, dyspnea, and fever. He was not on active therapy for his malignancy. He previously received a trial regimen of coenzyme Q10, 12 g every 3 days, from October 2015 to April 2016. His past medical history was remarkable for two prior episodes of ascites and 3 months of progressive liver dysfunction and coagulopathy . He had atorvastatin-induced myalgias leading to its discontinuation in April 2016 although his creatine kinase levels were not elevated. He was taking increasing doses of acetaminophen (2 grams daily) prior to admission. His physical examination vital signs were stable with one recorded febrile episode. In general, he appeared ill and lethargic, and was only oriented to person. He exhibited diminished bibasilar breath sounds, ascites with guarding, hypoactive bowel sounds, right lower quadrant tenderness, and hepatosplenomegaly.\nLaboratory data were remarkable for hyperferritinemia, hypofibrinogenemia, anemia, and thrombocytopenia along with elevated transaminases and coagulopathy . A peripheral blood smear showed neutrophilia, monocytosis, and reticulocytopenia. No microangiopathic changes were seen. Extensive platelet clumping was noted.\nImaging studies revealed small pleural effusions, ascites, and hepatosplenomegaly with no evidence of portal hypertension or splanchnic thrombosis. We were suspicious of HLH in light of laboratory and physical examination findings. Additional differential diagnosis workup – infectious, autoimmune, acetaminophen levels – yielded unremarkable results, including: serology for hepatitis A virus (HAV), hepatitis B virus (HBV), hepatitis C virus (HCV), hepatitis E virus (HEV), cytomegalovirus (CMV), Epstein–Barr virus (EBV), herpes simplex virus (HSV), alpha 1-antitrypsin levels, and antinuclear, anti-mitochondrial, anti-smooth muscle, and transglutaminase antibodies (immunoglobulin A (IgA) and immunoglobulin G (IgG)). ADAMTS 13 activity was >34%. HLH-specific laboratory studies were sent, including soluble CD25 (sCD25), NK cell activity studies, and bone marrow biopsy.\nHe continued to deteriorate with multiple organ failure including renal failure, myocardial injury, and respiratory failure requiring intubation. Empiric therapy, considering the evidence of liver injury and the possibility of HLH, with N-acetylcysteine on a 20-hour intravenous protocol and dexamethasone 8 mg intravenously administered three times daily was initiated. HLH chemotherapy was not done during this time as hepatotoxicity risk outweighed benefits and a definite diagnosis was not confirmed.\nAs an attempt to expedite the evaluation of possible HLH, we isolated mononuclear cells from peripheral blood and evaluated expression of surface markers in cytokine-producing NK cells and cytotoxic NK cells by flow cytometry. We compared the profile with normal controls. The results, available after 36 hours, were remarkable for an increased expression of CD69 in cytotoxic NK cells, and decreased NKG2A in cytokine-producing NK cells in our case. The expression of CD69 and NKG2A in NK cells was evaluated in four other normal donors and the results were similar to the one acquired in parallel to the HLH sample . No differences in protein expression of other markers were observed by flow cytometry (data not shown). These findings included similar surface levels of OX40, GITR, 4-1BB, TIM-3, PD-1, CTLA-4, LAG-3, and ICOS in CD8+ CD3+ T cells, as well as effector (CD127+, FoxP3-) and regulatory (CD127-, FoxP3+) CD4+ CD3+ T cells; similar expression of NKp44, NKG2C, NKG2D, 4-1BB, NKp30, and NKp46 in NK cells (CD56+ CD3-); and similar expression of CD28, CD27, ICOS, Eomes, Blimp-1, Bcl-6, T-bet, Ki-67, and cMyc in naïve (CCR7+ CD45RA+), effector (CCR7- CD45RA+), effector memory (CCR7-CD45RA-), and central memory (CCR7+ CD45RA-) CD4+ and CD8+ T cells. The frequency of all the evaluated immune cell populations was also similar, when comparing cells from our patient with those ones from a healthy control.\nOur patient’s bone marrow biopsy was performed 10 days after admission and delayed due to severe coagulopathy and demonstrated normocellularity (40 to 50%), megakaryocytic hypoplasia, and clusters of foamy histiocytes with ingested marrow cells. Fifteen days after admission, he fulfilled multiple HLH-2004 diagnostic criteria including hyperferritinemia, fever, splenomegaly, cytopenias, hemophagocytosis on biopsy of bone marrow, elevated CD25, and decreased NK cell activity by standardized studies .\nHe steadily recovered with the steroid therapy instituted for 12 days and supportive measures. He was weaned off intubation and sedation. However, he refused further interventions for HLH, namely etoposide-based therapy and continuation of steroid treatment; he chose palliative care and died 2 weeks later.", "summary": "We describe the case of a 54-year-old white man with history of metastatic maxillary sinus adenoid cystic carcinoma who had severe liver injury and cytopenias with progressive clinical deterioration. We performed an evaluation, by flow cytometry, of the expression of surface markers in his natural killer cells that revealed remarkable abnormalities. His syndrome eventually fulfilled criteria for hemophagocytic lymphohistiocytosis and he received therapy with steroids with interval clinical improvement. Unfortunately, he refused further cytotoxic treatment and died 2 weeks later.", "subclaim_evaluations": [ { "subclaim": "The patient is a 54-year-old white man.", "support_label": "supported", "is_refined": false }, { "subclaim": "The patient had a history of metastatic maxillary sinus adenoid cystic carcinoma.", "support_label": "supported", "is_refined": false }, { "subclaim": "The patient had severe liver injury.", "support_label": "supported", "is_refined": false }, { "subclaim": "The patient had cytopenias.", "support_label": "supported", "is_refined": false }, { "subclaim": "The patient had progressive clinical deterioration.", "support_label": "supported", "is_refined": false }, { "subclaim": "An evaluation of the expression of surface markers in his natural killer cells was performed by flow cytometry.", "support_label": "supported", "is_refined": false }, { "subclaim": "The evaluation revealed remarkable abnormalities.", "support_label": "supported", "is_refined": false }, { "subclaim": "The syndrome eventually fulfilled criteria for hemophagocytic lymphohistiocytosis.", "support_label": "supported", "is_refined": false }, { "subclaim": "The patient received therapy with steroids.", "support_label": "supported", "is_refined": false }, { "subclaim": "The patient had interval clinical improvement.", "support_label": "supported", "is_refined": false }, { "subclaim": "The patient refused further cytotoxic treatment.", "support_label": "supported", "is_refined": false }, { "subclaim": "The patient died 2 weeks later.", "support_label": "supported", "is_refined": false } ] }, { "id": "multiclinsum_test_992_en.txt", "fulltext": "A 23-year-old woman was referred to the Oral and Maxillofacial Surgery Service of\nAssociação Paulista de Cirurgiões-Dentistas 30 days after accidental extraction of a\nmandibular second molar during extraction of a third molar on the left side. and show the panoramic radiographs taken before and after extractions, respectively. The\npatient also reported that the surgeon had considerable difficulty during the surgical\nprocedure, which imposed an extensive period of time with the mouth opened. She reported\nsevere joint pain on the right side soon after surgery, accompanied by difficulty in\nmouth opening and a deviation to the opposite side of the extractions.\nClinical examination also revealed 23-mm mouth opening , with normal eccentric movement to the ipsilateral side and\nrestriction of eccentric movement to the contralateral side . The following hypotheses were considered: permanent trismus,\nmandibular fracture or ADDWoR on the right side of the TMJ. Patient denied having\nhistory of symptoms related to TMD before surgery. Magnetic resonance imaging (MRI)\nconfirmed ADDWoR on the right side of the TMJ .\nThe patient was advised to try to reduce deviation by performing lateral movements, as\nmuch as possible, to the contralateral side of displacement, and, from this position,\ntry to reach maximum mouth opening. At that time, no increase in mandibular opening and\nlaterality was observed. Thus, two attempts of manual manipulation were performed within\nthe period of one week. In the first attempt, we chose to test mandibular reduction\nusing extraoral anesthesia alone. Due to failure and patient's discomfort, we decided to\nwait a week before making a new attempt. At this time, we applied the same type of\nextraoral anesthesia associated with intravenous sedation, thus contributing to\nsuccessful reduction of disc displacement.\nExtraoral anesthesia was applied by blocking the auriculotemporal nerve with 1.8 ml of\n2% lidocaine hydrochloride associated with norepinephrine 1:200,000, followed by\nanesthesia of masseteric and posterior deep temporal nerves with the same amount of\nanesthetics. With a view to providing the patient with greater comfort, an intravenous\ninjection of 2 g midazolam hydrochloride was administered ten minutes before the manual\nreduction procedure . Thus, 40-mm mouth\nopening and immediate improvement of mandibular functions were achieved .\nMinagi et al's technique for mandibular\nmanipulation was used. It assists patients in performing maximum lateral excursive jaw\nmovements to the nonaffected side with teeth slightly occluded, and in making maximal\njaw opening movements through lateral border movements, as follows: 1) Place the thumb\nand forefinger on the maxillary canine on the nonaffected side and the mandibular canine\non the affected side. Hold the gonion with the forefinger and middle finger of the other\nhand. 2) Instruct the patient to make maximal lateral gliding excursive jaw movements to\nthe nonaffected side with teeth slightly occluded. Support movement with fingers and\nensure that lateral excursive position is maximal. Lateral excursion with the jaw\nprotruding is not adequate for this procedure. 3) Subsequently, instruct the patient to\nmake jaw opening movements through the lateral border path on the nonaffected side.\nSupport this opening movement with assisting fingers. 4) Continue to support voluntary\nmouth opening up to the maximal opening position.\nThe patient received a prescription of anti-inflammatory drugs (100 mg of nimesulide,\n12/12 hours, orally) during five days, and also was advised not to force mandibular\nmovements after reduction. The patient was instructed to use a stabilizer plate\nimmediately after correct manipulation, so as to avoid a new disc displacement and\nreduce muscle hyperactivity. There were no complications after the manipulation\nmaneuver, and an immediate 40-mm mouth opening was achieved after manual manipulation\n. The patient was followed-up on a\nweekly basis in the first month and every two weeks until the third month, showing no\nepisodes of TMD within this period. and show MRI sagittal slices of the right TMJ\nwith closed mouth presenting disc displacement and in maximum mouth opening movement,\nevincing reduction of TMJ articular disc.", "summary": "The patient presented severe limitation to fully open the mouth, interfering in her ability to eat. Clinical examination also revealed maximum assisted jaw opening (passive stretch) with less than 40 mm of maximum interincisal opening. Magnetic resonance imaging was the method of choice to identify the temporomandibular disorders.", "subclaim_evaluations": [ { "subclaim": "The patient had severe limitation to fully open the mouth.", "support_label": "supported", "is_refined": false }, { "subclaim": "The limitation interfered with her ability to eat.", "support_label": "supported", "is_refined": false }, { "subclaim": "Clinical examination revealed maximum assisted jaw opening.", "support_label": "supported", "is_refined": false }, { "subclaim": "The maximum interincisal opening was less than 40 mm.", "support_label": "not_supported", "original_label": "not_supported", "reasoning_audit": "No explicit tags provided.", "is_refined": true }, { "subclaim": "Magnetic resonance imaging was the method of choice.", "support_label": "supported", "is_refined": false }, { "subclaim": "Magnetic resonance imaging was used to identify temporomandibular disorders.", "support_label": "supported", "is_refined": false } ] }, { "id": "multiclinsum_test_1996_en.txt", "fulltext": "Our work is a single case report and has been reported in line with the SCARE criteria .\nA healthy 59-year-old woman on long-term therapy with Hydroxyurea 500 mg daily for essential thrombocytosis, presented with a painless slow-growing lesion of the jaw that had persisted and increased in size for six months, the appearance of the lesion is correlated to the administration of the hydroxyurea treatment. There was no history of local trauma, radiotherapy, HPV infections, or family history of malignancy. She was referred to our department's consultation for specialized care. No other personal or family history was raised during the patient interrogation. Clinical examination revealed a large nodular lesion with irregular borders of the right cheek, infiltrated into underlying tissue, the lesion extending to the free border of the right lower eyelid with dimensions 4 × 4 cm, without sensory disturbances or diplopia (.). In the nose, black horn-shaped hyperkeratosis lesion in the nasal pyramid (.).\nThere were no palpable neck lymph nodes on the left side.\nA biopsy of surgical material was performed, showing a well-differentiated squamous cell carcinoma.\nThe definitive diagnosis of malignancy was made; metastatic investigations were performed, including chest radiography, abdominal echography, PET scan. The results of these exams were normal.\nThe computed tomography (CT) was performed and found free lymph node.\nOn the biological level, the patient presented anemia at 7.4 g / dl for which she was transfused; a thrombocytosis at 548.000, the rest of the assessment was without particularities.\nBased on the positive medical history and clinical examination, the patient was diagnosed clinically with hydroxyurea-induced squamous cell carcinoma, the hydroxyurea was ceased and the hematological therapy was switched to busulfan. The surgery was indicated and performed by the chief professor of our department who has 15 years of operative experience. The surgical procedure had the aim of the restoration of the anatomic landmarks after a large excision of the tumor and reconstruction of full-thickness eyelid defect with a local flap under general anesthesia.\nDuration of surgery: 60 min; estimation of blood loss: 150 ml; duration of hospital stay: 3 days.\nThe patient received amoxicillin/clavulanic acid 1 g twice daily and antalgics for 8 days.\nPost-operative histopathology confirmed SCC proliferation; the different margins of excision were healthy.\nThe multidisciplinary team deciding on the treatment options included surgeons, oncologists, radiotherapists, ophthalmologist surgeons, radiologists. The decision was made to treat the patient with the surgical approach (surgical excision of the tumor) with 1.5 cm free margins and reconstruction; the authors used the superior pedicle nasolabial island flap; with postoperative radiotherapy (PORT) and postoperative chemotherapy (POCRT). Considering the patient's age, general history, the size of the tumor, the prognosis was average.\nPostoperative periods were favorable; the scar was clean and non-inflammatory.\nRoutine follows up 3, 6, and 12 months showed no signs of recurrence.", "summary": "The authors report the case of a healthy 59-year-old woman on long-term therapy with Hydroxyurea 500 mg daily for essential thrombocytosis, presented with a painless slow-growing lesion of the jaw that had persisted and increased in size for six months, the appearance of the lesion is correlated to the administration of the hydroxyurea treatment. Clinical examination revealed a large nodular lesion 4 × 4 cm with irregular borders of the right cheek, infiltrated into underlying tissue, the lesion extending to the free border of the right lower eyelid without sensory disturbances or diplopia. The surgery was indicated. The surgical procedure had the aim of the restoration of the anatomic landmarks after a large excision of the tumor and reconstruction of full-thickness eyelid defect with a local flap under general anesthesia.", "subclaim_evaluations": [ { "subclaim": "The patient is a 59-year-old woman.", "support_label": "supported", "is_refined": false }, { "subclaim": "The patient had essential thrombocytosis.", "support_label": "supported", "is_refined": false }, { "subclaim": "The patient was on long-term therapy with Hydroxyurea 500 mg daily.", "support_label": "supported", "is_refined": false }, { "subclaim": "The patient had a painless slow-growing lesion of the jaw.", "support_label": "supported", "is_refined": false }, { "subclaim": "The lesion had persisted and increased in size for six months.", "support_label": "supported", "is_refined": false }, { "subclaim": "The appearance of the lesion is correlated to the administration of hydroxyurea treatment.", "support_label": "supported", "is_refined": false }, { "subclaim": "Clinical examination revealed a 4 × 4 cm nodular lesion of the right cheek.", "support_label": "supported", "is_refined": false }, { "subclaim": "The lesion had irregular borders.", "support_label": "supported", "is_refined": false }, { "subclaim": "The lesion infiltrated into underlying tissue.", "support_label": "supported", "is_refined": false }, { "subclaim": "The lesion extended to the free border of the right lower eyelid.", "support_label": "supported", "is_refined": false }, { "subclaim": "There were no sensory disturbances.", "support_label": "supported", "is_refined": false }, { "subclaim": "There was no diplopia.", "support_label": "supported", "is_refined": false }, { "subclaim": "Surgery was indicated.", "support_label": "supported", "is_refined": false }, { "subclaim": "The surgical procedure aimed to restore anatomic landmarks.", "support_label": "supported", "is_refined": false }, { "subclaim": "The surgical procedure involved a large excision of the tumor.", "support_label": "supported", "is_refined": false }, { "subclaim": "The surgical procedure included reconstruction of a full-thickness eyelid defect.", "support_label": "supported", "is_refined": false }, { "subclaim": "The reconstruction was performed with a local flap.", "support_label": "supported", "is_refined": false }, { "subclaim": "The procedure was performed under general anesthesia.", "support_label": "supported", "is_refined": false } ] }, { "id": "multiclinsum_test_310_en.txt", "fulltext": "A 64-year-old man visited the local medical center on March 4th with a complaint of general weakness, myalgia, and abdominal pain, which had begun a week prior to the visit.\nThe patient underwent computed tomography (CT) at the local medical center where he was diagnosed with thrombosis of the SMV, and was subsequently transferred to our hospital. The abdominal CT scan revealed a large thrombus running straight from the SMV gastrocolic trunk to the distal site, totally obstructing a segmental portion of the SMV. Additionally, the surrounding fat stranding and bowel wall edema of the ascending colon were confirmed.\nThe patient had a fever of 37.9 °C at the time of the visit, and complained that he felt hot. He also complained of a headache, but there was no cough, sputum, diarrhea, or vomiting.\nOver the previous 5-years, the patient had been prescribed 1000 mg metformin once daily (Q.D.), 1 mg glimepiride Q.D., 2.5 mg linagliptin Q.D., 50 mg losartan Q.D., and 10 mg rosuvastatin Q.D. for hypertension and diabetes.\nThe patient continued to complain of a dull pressing pain in the right upper quadrant, with mild tenderness in the area during the physical examination. The bowel sound was hypo-active, and there were no other specific findings in other physical examinations.\nBlood tests revealed that the white blood cell count was 16160 /mL, the level of ESR was 86 mm/hr, and the level of HS-CRP was 16 mg/dL. Although SMV thrombosis was diagnosed, the patient only complained of mild tenderness, and no rebound tenderness. However, there were complaints of fever and muscle pain throughout the body. Since the patient’s symptoms were considered atypical for SMV thrombosis, a sample was collected through a nasopharyngeal swab and an Influenza A/B rapid antigen test was performed. The influenza test was performed using \"The BD Veritor™ Plus System for Rapid Detection of Flu A+B\" kit, sensitivity 81.3% (71.1%, 88.5%, 95% confidence interval), specificity 98.2% (95.7%, 99.3%, 95% confidence interval). In addition, after collecting samples through nasopharyngeal swab, coronavirus disease-2019 (COVID-19) test by RT-PCR was performed by taking account of recent pandemic situation.\nThe abdominal CT scan revealed a large thrombus running straight from the SMV gastrocolic trunk to the distal site, totally obstructing a segmental portion of the SMV. Additionally, the surrounding fat stranding and bowel wall edema of the ascending colon were confirmed.", "summary": "A 64-year-old male visited the hospital with general weakness, muscle aches, fever, and abdominal pain. The patient underwent computed tomography (CT) and was diagnosed with SMV thrombosis. Since the patient's muscle pain and fever could not be explained by the SMV thrombosis, the clinician performed a test for influenza, which produced a positive result for influenza B. The patient had a thrombus in the SMV only, with no invasion of the portal or splenic veins, and was clinically stable. Anticoagulation treatment was prescribed without surgery or other procedures. The follow-up CT scan showed improvement, and the patient was subsequently discharged with continued oral anticoagulant treatment.", "subclaim_evaluations": [ { "subclaim": "The patient is a 64-year-old male.", "support_label": "supported", "is_refined": false }, { "subclaim": "The patient had general weakness.", "support_label": "supported", "is_refined": false }, { "subclaim": "The patient had muscle aches.", "support_label": "supported", "is_refined": false }, { "subclaim": "The patient had fever.", "support_label": "supported", "is_refined": false }, { "subclaim": "The patient had abdominal pain.", "support_label": "supported", "is_refined": false }, { "subclaim": "The patient underwent computed tomography.", "support_label": "supported", "is_refined": false }, { "subclaim": "The patient was diagnosed with SMV thrombosis.", "support_label": "supported", "is_refined": false }, { "subclaim": "The patient's muscle pain could not be explained by the SMV thrombosis.", "support_label": "supported", "is_refined": false }, { "subclaim": "The patient's fever could not be explained by the SMV thrombosis.", "support_label": "supported", "is_refined": false }, { "subclaim": "The clinician performed a test for influenza.", "support_label": "supported", "is_refined": false }, { "subclaim": "The influenza test result was positive for influenza B.", "support_label": "not_supported", "original_label": "not_supported", "reasoning_audit": "No explicit tags provided.", "is_refined": true }, { "subclaim": "The patient had a thrombus in the SMV.", "support_label": "supported", "is_refined": false }, { "subclaim": "The thrombus did not invade the portal vein.", "support_label": "not_supported", "original_label": "not_supported", "reasoning_audit": "No explicit tags provided.", "is_refined": true }, { "subclaim": "The thrombus did not invade the splenic vein.", "support_label": "supported", "is_refined": false }, { "subclaim": "The patient was clinically stable.", "support_label": "not_supported", "original_label": "not_supported", "reasoning_audit": "No explicit tags provided.", "is_refined": true }, { "subclaim": "Anticoagulation treatment was prescribed.", "support_label": "not_supported", "original_label": "not_supported", "reasoning_audit": "No explicit tags provided.", "is_refined": true }, { "subclaim": "No surgery was performed.", "support_label": "supported", "is_refined": false }, { "subclaim": "No other procedures were performed.", "support_label": "not_supported", "original_label": "not_supported", "reasoning_audit": "No explicit tags provided.", "is_refined": true }, { "subclaim": "The follow-up CT scan showed improvement.", "support_label": "not_supported", "original_label": "not_supported", "reasoning_audit": "No explicit tags provided.", "is_refined": true }, { "subclaim": "The patient was discharged.", "support_label": "not_supported", "original_label": "not_supported", "reasoning_audit": "No explicit tags provided.", "is_refined": true }, { "subclaim": "The patient received continued oral anticoagulant treatment.", "support_label": "not_supported", "original_label": "not_supported", "reasoning_audit": "No explicit tags provided.", "is_refined": true } ] }, { "id": "multiclinsum_test_3354_en.txt", "fulltext": "62-year-old previously healthy female hiker and climber presented with dizziness, imbalance, and gait instability that developed rapidly within a few weeks in 2016. Subacute cerebellar ataxia was suspected and a number of studies including oncological blood tests, oncological neuronal antibodies, brain and body PET, cerebrospinal fluid examination, brain imaging, and genetic testing for ataxia were performed with no positive findings. After an initial plateau of symptoms, the patient entered a slow and progressive neurological decline with late-onset idiopathic cerebellar ataxia as the most likely diagnosis. After multiple medical consultations, she came to our center in 2022. The patient denied a family history, frequent cough, digestive problems, and autonomic disorders. The neurological examination showed unstable, wide-based gait and a positive Romberg test. She presented dysarthria, vertical descending nystagmus in primary gaze, and lateral gaze nystagmus. The slow eye tracking was fragmented and the visual suppression of the normal vestibulo-ocular reflex was observed. The head impulse test and dynamic visual acuity were abnormal. In addition, symmetrical bilateral inframalleolar hypalesthesia and presenting vestibulo-neuromuscular reflexes were observed. No autonomic weakness or muscle weakness was detected in the extremities. In summary, the patient with no relevant family history developed a late-onset idiopathic cerebellar ataxia with diverse neurological manifestations including sensory and vestibular disorders, while the studies performed did not yield a specific diagnosis. Complementary studies: To revalidate the clinical diagnosis of a mixed vestibulo-cerebellar dysfunction, a 3 Tesla magnetic resonance of the brain (MRI), a video head impulse test (VHIT) and vestibulo-myogenic evoked potentials (VEMPS) were performed along with sensory potentials of the four limbs. The MRI of the brain showed a discrete cerebellar vermiform and para-vermiform atrophy without focal structural damage. The vestibulo-myogenic evoked potentials showed a severe global vestibular hyporeflexia. Genetic studies: A clinical exome study was performed, using next-generation sequencing (NGS), to search for point and small insertion/deletion variants on a panel of 677 candidate genes according to the patient's phenotype, mainly associated with spinocerebellar ataxia, which was negative. Subsequently, a specific genetic study for intronic expansion in the RFC1 gene was performed, which was consistent with the presence of a pathogenic AAGGG motif biallelic expansion. These findings of bilateral vestibulopathy associated with cerebellar ataxia and sensory neuronopathy suggested the diagnosis of CANVAS, which was confirmed by the identification of biallelic expansion of the RFC1 gene in genetic testing.\n", "summary": "We present the case of a 62-year-old woman with a history of bi-phasic onset gait imbalance and deterioration, with a rapid onset of symptoms followed by slow and progressive neurological deterioration. The diagnostic process was complex and numerous tests were performed to exclude acquired and genetic causes of ataxia, leading to the diagnosis of idiopathic late-onset cerebellar ataxia. Subsequently, vestibular function tests identified a severe bilateral vestibulopathy. This led to consideration of CANVAS as a diagnosis, which was finally confirmed by genetic testing (biallelic expansion of the penta-nucleotide AAGGG in the RFC1 gene).\n", "subclaim_evaluations": [ { "subclaim": "The patient is a 62-year-old woman.", "support_label": "supported", "is_refined": false }, { "subclaim": "She had bi-phasic onset gait imbalance and deterioration.", "support_label": "supported", "is_refined": false }, { "subclaim": "Her symptoms had a rapid onset followed by slow and progressive neurological deterioration.", "support_label": "supported", "is_refined": false }, { "subclaim": "Numerous tests were performed to exclude acquired and genetic causes of ataxia.", "support_label": "supported", "is_refined": false }, { "subclaim": "The diagnosis was idiopathic late-onset cerebellar ataxia.", "support_label": "not_supported", "original_label": "not_supported", "reasoning_audit": "No explicit tags provided.", "is_refined": true }, { "subclaim": "Vestibular function tests identified a severe bilateral vestibulopathy.", "support_label": "supported", "is_refined": false }, { "subclaim": "CANVAS was considered as a diagnosis.", "support_label": "supported", "is_refined": false }, { "subclaim": "CANVAS was confirmed by genetic testing.", "support_label": "supported", "is_refined": false }, { "subclaim": "The genetic test showed biallelic expansion of the penta-nucleotide AAGGG in the RFC1 gene.", "support_label": "supported", "is_refined": false } ] }, { "id": "multiclinsum_test_2163_en.txt", "fulltext": "A 64-year-old man who came to our emergency department complaining of left shoulder pain.\nHe had mild left shoulder trauma due to accidental falling from the standing position while walking 3 h ago.\nHis past medical history included atrial fibrillation treated with aspirin enteric-coated tablets (Bayer SPA), metoprolol succinate sustained-release tablets (AstraZeneca AB), and chronic atrophic gastritis.\nThe patient denied a history of smoking, alcohol consumption, drug intake, and a family history of pathological fracture or osteoporosis.\nPhysical examination demonstrated swelling of the left shoulder, localized tenderness, percussion pain on the proximal humerus, and limited shoulder motion. The muscular tone of the upper limb was normal with no hypoesthesia. Physiological reflexes were present without pathological reflexes.\nIn contrast, routine laboratory evaluation on admission, with the exception of anemia, was unremarkable. Hematopoiesis accounted for 40%, the ratio of granulocytes to erythrocytes was approximately 2:1, and megakaryocytes were 2-7/high power field. Multifocal plasmacytoid cell aggregation was also observed. Immunochemistry showed CD38 (+), kappa (+), lambda (+); MPO (+), CD61 (+) and CK (-) .\nInitial X-ray films of the left shoulder were obtained, which showed only a comminuted fracture and degenerative changes in the upper left humerus . Magnetic resonance imaging (MRI) was then performed and showed an abnormal signal intensity of the proximal humerus associated with a comminuted fracture, and multiple soft tissue masses around the fracture, ranging from 4.8 cm to 3.9 cm, which presented as hypointensity and isointensity, as well as hybrid hyperintensity on T1-weighted (T1-W) and T2-W images, respectively. The left humerus, glenoid, and clavicle had multiple sheet-like hyperintensity on T2-W images . A neoplastic lesion with radiological characteristics was highly suspected.\nFurther laboratory tests and imaging examinations were performed. Computed tomography (CT) scans and X-ray examinations revealed multiple areas of reduced bone density throughout the body. In addition, high 18-F-fluorodeoxyglucose metabolism was observed in several ribs on bone scans, and in the fifth lumbar vertebra (L5), and left proximal humerus .", "summary": "A 64-year-old male patient complaining of serious left shoulder pain and limited movement was admitted. The patient was finally diagnosed with MM (IgAλ, IIIA/II). After treatment of the pathological fracture with IM nailing, the patient's function recovered and his pain was rapidly relieved. Histopathological examination demonstrated plasma cell myeloma. The patient received chemotherapy in the Hematology Department. The humeral fracture displayed good union during the 40-mo follow-up, with complete healing of the fracture, and the clinical outcome was satisfactory. At the most recent follow-up, the patient's function was assessed using the Musculoskeletal Tumor Society score, which was 29.", "subclaim_evaluations": [ { "subclaim": "The patient is a 64-year-old male.", "support_label": "supported", "is_refined": false }, { "subclaim": "The patient complained of serious left shoulder pain.", "support_label": "supported", "is_refined": false }, { "subclaim": "The patient had limited movement.", "support_label": "supported", "is_refined": false }, { "subclaim": "The patient was diagnosed with MM (IgAλ, IIIA/II).", "support_label": "not_supported", "original_label": "not_supported", "reasoning_audit": "No explicit tags provided.", "is_refined": true }, { "subclaim": "The patient had a pathological fracture.", "support_label": "supported", "is_refined": false }, { "subclaim": "The pathological fracture was treated with IM nailing.", "support_label": "not_supported", "original_label": "not_supported", "reasoning_audit": "No explicit tags provided.", "is_refined": true }, { "subclaim": "The patient's function recovered after treatment.", "support_label": "not_supported", "original_label": "not_supported", "reasoning_audit": "No explicit tags provided.", "is_refined": true }, { "subclaim": "The patient's pain was rapidly relieved after treatment.", "support_label": "not_supported", "original_label": "not_supported", "reasoning_audit": "No explicit tags provided.", "is_refined": true }, { "subclaim": "Histopathological examination demonstrated plasma cell myeloma.", "support_label": "not_supported", "original_label": "not_supported", "reasoning_audit": "No explicit tags provided.", "is_refined": true }, { "subclaim": "The patient received chemotherapy in the Hematology Department.", "support_label": "not_supported", "original_label": "not_supported", "reasoning_audit": "No explicit tags provided.", "is_refined": true }, { "subclaim": "The humeral fracture displayed good union during the 40-mo follow-up.", "support_label": "not_supported", "original_label": "not_supported", "reasoning_audit": "No explicit tags provided.", "is_refined": true }, { "subclaim": "The fracture completely healed.", "support_label": "not_supported", "original_label": "not_supported", "reasoning_audit": "No explicit tags provided.", "is_refined": true }, { "subclaim": "The clinical outcome was satisfactory.", "support_label": "not_supported", "original_label": "not_supported", "reasoning_audit": "No explicit tags provided.", "is_refined": true }, { "subclaim": "The patient's function was assessed using the Musculoskeletal Tumor Society score.", "support_label": "not_supported", "original_label": "not_supported", "reasoning_audit": "No explicit tags provided.", "is_refined": true }, { "subclaim": "The Musculoskeletal Tumor Society score was 29.", "support_label": "not_supported", "original_label": "not_supported", "reasoning_audit": "No explicit tags provided.", "is_refined": true } ] }, { "id": "multiclinsum_test_2745_en.txt", "fulltext": "A 29-year-old woman was diagnosed with aortic coarctation and a bicuspid aortic valve. The patient underwent a left subclavian flap aortoplasty 1 month after birth and balloon dilatation for re-coarctation at the age of 8 years. She subsequently self-discontinued outpatient follow-ups. At the age of 26 years, she was diagnosed with hypertension and referred to our hospital as her contrast-enhanced computerized tomography scan revealed re-coarctation. Her height was 152 cm, weight 53 kg, heart rate 90 b.p.m., percutaneous arterial oxygen saturation 97% (room air), right upper extremity blood pressure (BP) 152/89 mmHg, and right lower extremity BP 120/93 mmHg. She had a Levine III/VI systolic murmur at the second intercostal space left sternal border and left back. The patient occasionally noticed fatigue in her legs when walking. Laboratory findings revealed an N-terminal prohormone of brain natriuretic peptide of 50.6 pg/mL. A chest radiography revealed a cardiothoracic ratio of 48% and no rib notch sign. A 12-lead electrocardiogram revealed sinus rhythm with sV1 + rV5 of 2.6 mV. Echocardiography revealed an LV end-diastolic diameter of 44.6 mm, a posterior wall of 7.9 mm, and an ejection fraction rate of 79%. The LV inflow waveform had a normal pattern with E/A > 1. The blood flow velocity at the re-coarctation was 3.2 m/s. The abdominal aortic blood flow waveform was blunted, and the systolic upstroke delayed. Cardiac catheterization revealed an LV pressure of 152/e12 mmHg, a re-coarctation area of 7.0 × 5.3 mm, and a systolic pressure gradient (PG) of 40 mmHg . One month after catheterization, the patient underwent balloon dilatation. Subsequently, the re-coarctation area expanded to 10.0 mm × 10.5 mm, and the systolic PG improved to 6 mmHg . After patient consent, we used 4D flow MRI for research purposes to evaluate the large vessel and LV blood flow before and after treatment. Cardiac MRI was a 3.0 T whole-body imager (MAGNETOM Vida 3 T; Siemens Healthcare, Erlangen, Germany). Scan parameters included: acceleration method, GRAPPA 3; field of view, 340 × 340 mm; flip angle, 8°; temporal resolution, 41 ms; a retrospectively electrocardiogram triggered. The acquired voxel size was 2.5 × 2.5 × 2.5 mm3, with velocity encoding 150 cm/s, Segment 2, and 30 frames/cycle. A workstation (cvi42, ver 5.17.0, Circle, Cardiovascular Imaging, Calgary, Canada) was used for the analysis.\nPreoperatively, helical flow was observed in the ascending and descending aorta ( and ). The LV blood flow analysis revealed 39.1% direct flow, 21.7% delayed ejection flow, 23.4% retained inflow, and 15.9% residual volume. Details of the four blood flow components and data on normal subjects are shown ( and , ). No obvious intraventricular blood flow ratio abnormality was observed . However, kinetic energy (KE) values of direct flow and delayed ejection flow decreased during systole . Postoperatively, helical flow in the descending aorta was alleviated ( and ). Left ventricular blood flow analysis revealed 39% direct flow, 19.4% delayed ejection flow, 22% retained inflow, and 19.5% residual volume . Although no change was observed in the direct flow ratio, an increase in KE values of direct flow and delayed ejection flow during systole was observed . Left ventricular function and volumes did not change before and after treatment. Two months after treatment, the systolic BP decreased by 20 mmHg.", "summary": "A 29-year-old female was diagnosed with coarctation of the aorta and a bicuspid aortic valve after birth and underwent surgery at 1 month. At 8 years of age, she underwent balloon dilatation for re-coarctation. At the age of 28 years, she was diagnosed with re-coarctation triggered by hypertension. She underwent balloon dilatation as her cardiac catheterization revealed a systolic pressure gradient of 40 mmHg. Pretreatment 4D flow MRI demonstrated helical flow in the ascending aorta and descending thoracic aorta and LV blood flow analysis revealed a decrease in LV kinetic energy during systole; these improved after treatment.", "subclaim_evaluations": [ { "subclaim": "The patient is a 29-year-old female.", "support_label": "supported", "is_refined": false }, { "subclaim": "She was diagnosed with coarctation of the aorta after birth.", "support_label": "supported", "is_refined": false }, { "subclaim": "She was diagnosed with a bicuspid aortic valve after birth.", "support_label": "supported", "is_refined": false }, { "subclaim": "She underwent surgery for coarctation of the aorta at 1 month of age.", "support_label": "supported", "is_refined": false }, { "subclaim": "At 8 years of age, she underwent balloon dilatation for re-coarctation.", "support_label": "supported", "is_refined": false }, { "subclaim": "At 28 years of age, she was diagnosed with re-coarctation.", "support_label": "not_supported", "original_label": "not_supported", "reasoning_audit": "No explicit tags provided.", "is_refined": true }, { "subclaim": "Her re-coarctation at 28 years was triggered by hypertension.", "support_label": "not_supported", "original_label": "not_supported", "reasoning_audit": "No explicit tags provided.", "is_refined": true }, { "subclaim": "She underwent balloon dilatation for re-coarctation.", "support_label": "supported", "is_refined": false }, { "subclaim": "Cardiac catheterization revealed a systolic pressure gradient of 40 mmHg.", "support_label": "supported", "is_refined": false }, { "subclaim": "Pretreatment 4D flow MRI showed helical flow in the ascending aorta.", "support_label": "supported", "is_refined": false }, { "subclaim": "Pretreatment 4D flow MRI showed helical flow in the descending thoracic aorta.", "support_label": "supported", "is_refined": false }, { "subclaim": "LV blood flow analysis showed a decrease in LV kinetic energy during systole.", "support_label": "supported", "is_refined": false }, { "subclaim": "LV kinetic energy improved after treatment.", "support_label": "supported", "is_refined": false } ] }, { "id": "multiclinsum_test_2309_en.txt", "fulltext": "A 4-day-old male infant, who was born at 40 weeks’ gestational age and weighing 3660 g. He was delivered at term by episiotomy combined with forceps and admitted to the Department of Neonatology of The Second Hospital of Jilin University due to dyspnea in February 2022. No cutaneous lesions were observed. The patient underwent brain magnetic resonance imaging (MRI), the results of which showed a short T1 strip signal shadow (hemorrhage) under the cranial plate of the occipital region on both sides. He had no family history of diseases.The right eye appeared normal in the routine retinal screening performed with RetCam 3 (Clarity Medical Systems, Inc., Pleasanton, CA, USA). However, a color fundus photograph of the left eye revealed a solitary yellowish-white flat mass with an approximate size of 1.5-disc diameters located in the nasal retina . Diffuse hyperfluorescence with slight fluorescence leakage was observed by fluorescein angiography (FA) . On B-scan ultrasound, the mass was inapparent, with no distinct foci of calcification. No treatment was administered and follow-up reexaminations were recommended. Three months later, regression in the size of the retinal mass was observed . FA showed decreased vascularization of the lesion and slight mottled hyperfluorescence over its surface . Seven months later, the fundus examination indicated no lesion in the left eye . FA showed mild tortuous vessels without leakage . The right retina was normal, and thus the clinical course suggested that the isolated RAH may undergo spontaneous regression.", "summary": "An isolated retinal astrocytic hamartoma was detected in the nasal retina of the left eye of a 4-day-old male infant. At the time of initial presentation, we detected a solitary yellowish-white flat mass with an approximate size of 1.5 disc diameters in the nasal retina. Fluorescein angiography (FA) revealed a diffuse hyperfluorescence with slight fluorescence leakage. Seven months later, the fundus examination showed no lesion in the left eye, FA revealed mild tortuous vessels without leakage.", "subclaim_evaluations": [ { "subclaim": "An isolated retinal astrocytic hamartoma was detected in the nasal retina of the left eye of a 4-day-old male infant.", "support_label": "supported", "is_refined": false }, { "subclaim": "The lesion was a solitary yellowish-white flat mass.", "support_label": "supported", "is_refined": false }, { "subclaim": "The lesion was approximately 1.5 disc diameters in size.", "support_label": "supported", "is_refined": false }, { "subclaim": "Fluorescein angiography revealed diffuse hyperfluorescence.", "support_label": "supported", "is_refined": false }, { "subclaim": "Fluorescein angiography showed slight fluorescence leakage.", "support_label": "supported", "is_refined": false }, { "subclaim": "Seven months later, the fundus examination showed no lesion in the left eye.", "support_label": "supported", "is_refined": false }, { "subclaim": "Seven months later, fluorescein angiography revealed mild tortuous vessels.", "support_label": "supported", "is_refined": false }, { "subclaim": "Seven months later, fluorescein angiography showed no leakage.", "support_label": "supported", "is_refined": false } ] }, { "id": "multiclinsum_test_3199_en.txt", "fulltext": "A 20-year-old primigravida woman who did not remember her last menstrual period but stated that she had been amenorrheic for the past 6 months was referred to our hospital with a diagnosis of second trimester pregnancy plus disseminated intravascular coagulation (DIC) plus missed abortion and complained of lower abdominal pain for 1-week duration. Associated with this, she experienced easy fatigability, dizziness, blurred vision, and vertigo of the same duration.\n\nPhysical examination revealed blood pressure of 85/50 mmHg, with a pulse rate of 126 beats per minute (bpm). The patient had pale conjunctiva and tender abdomen. Obstetric ultrasound examination revealed a 22-week consistent pregnancy in the peritoneum, negative fetal heartbeat, empty uterus, and free fluid in Douglas and Morrison’s pouch. Laboratory results showed a hemoglobin concentration of 4.3 g/dL.\n\nOwing to unstable vital signs, the patient was transfused with three units of screened, cross-matched whole blood. After informed consent was obtained, the patient was rushed to the operating theatre with a preoperative diagnosis of uterine rupture.\n\nIntraoperative findings revealed hemoperitoneum of 2L, 500gm freshly dead male fetus and placenta, respectively. Further inspection revealed a bicornuate uterus and fundal uterine rupture in the left uterine segment. The hemoperitoneum was suctioned, the placenta and fetus were removed, and the uterus was repaired using a size 1 Vicryl suture.\n\nThe patient’s postoperative recovery was uneventful, and she was discharged on her fifth postoperative day. The patient was counselled on family planning for at least one year, and any future pregnancy would require elective cesarean delivery.", "summary": "A 20-year-old primigravid woman at 22 weeks of gestation, with no prior surgery, presented with severe abdominal pain, anemia, and hemodynamic instability. With a preoperative diagnosis of uterine rupture, she was transfused with three units of cross-matched whole blood and underwent emergency laparotomy. Intraoperative findings showed a ruptured bicornuate uterus and a dead fetus in the abdomen with huge hemoperitoneum. Postoperative recovery was smooth, and the patient was discharged after being counselled on family planning and subsequent pregnancy.", "subclaim_evaluations": [ { "subclaim": "The patient is a 20-year-old primigravid woman.", "support_label": "supported", "is_refined": false }, { "subclaim": "She is at 22 weeks of gestation.", "support_label": "supported", "is_refined": false }, { "subclaim": "She has no prior surgery.", "support_label": "not_supported", "original_label": "not_supported", "reasoning_audit": "No explicit tags provided.", "is_refined": true }, { "subclaim": "She presented with severe abdominal pain.", "support_label": "supported", "is_refined": false }, { "subclaim": "She had anemia.", "support_label": "supported", "is_refined": false }, { "subclaim": "She had hemodynamic instability.", "support_label": "supported", "is_refined": false }, { "subclaim": "The preoperative diagnosis was uterine rupture.", "support_label": "supported", "is_refined": false }, { "subclaim": "She was transfused with three units of cross-matched whole blood.", "support_label": "supported", "is_refined": false }, { "subclaim": "She underwent emergency laparotomy.", "support_label": "supported", "is_refined": false }, { "subclaim": "Intraoperative findings showed a ruptured bicornuate uterus.", "support_label": "supported", "is_refined": false }, { "subclaim": "A dead fetus was found in the abdomen.", "support_label": "supported", "is_refined": false }, { "subclaim": "There was a huge hemoperitoneum.", "support_label": "supported", "is_refined": false }, { "subclaim": "Postoperative recovery was smooth.", "support_label": "supported", "is_refined": false }, { "subclaim": "The patient was discharged after being counselled on family planning.", "support_label": "supported", "is_refined": false }, { "subclaim": "The patient was counselled on subsequent pregnancy.", "support_label": "supported", "is_refined": false } ] }, { "id": "multiclinsum_test_62_en.txt", "fulltext": "A 60-year-old male patient with metastatic colon cancer of the liver was referred to interventional radiology for right PVE prior to major hepatic resection.\nHe was diagnosed with sigmoid colon cancer and underwent anterior resection surgery 6 mo back. He developed liver metastasis for which right liver lobe resection was planned by a hepatobiliary surgeon. Due to a small left liver lobe, preoperative right PVE is requested to enhance the volume of the residual left liver lobe.\nHe is a known case of diabetes mellitus Type 2 Stage 3 on insulin and metformin for 9 years.\nHis personal and family history is unremarkable.\nGeneral examinations did not reveal any abnormality. Abdominal examinations revealed surgical scars from previous laparoscopic surgery and a stoma. No others abnormality could be detected.\nThe laboratory results of routine hematological testing, blood sedimentation rate, and tumor-associated markers were within normal limits. Alpha-fetoprotein is 14 ng/mL. Carcinoembryonic antigen is 2.4 ng/mL. Carbohydrate antigen 19-9 is 19 U/mL.\nHe underwent contrast-enhanced CT, which showed multiple right hepatic metastasis, small left hepatic lobe, and a normal patent portal venous system with a standard anatomy .", "summary": "A 60-year-old male presented with metastatic colon cancer of the liver. The patient underwent preoperative right PVE. During the embolization procedure, a small amount of glue and lipiodol emulsion was embolized to the heart and lungs through an unrecognized intrahepatic portosystemic fistula. The patient remained clinically stable and underwent the planned hepatic resection after 4 wk, with an uneventful postoperative course.", "subclaim_evaluations": [ { "subclaim": "The patient is a 60-year-old male.", "support_label": "supported", "is_refined": false }, { "subclaim": "The patient had metastatic colon cancer of the liver.", "support_label": "supported", "is_refined": false }, { "subclaim": "The patient underwent preoperative right portal vein embolization.", "support_label": "supported", "is_refined": false }, { "subclaim": "During the embolization procedure, a small amount of glue and lipiodol emulsion was embolized to the heart.", "support_label": "not_supported", "original_label": "not_supported", "reasoning_audit": "No explicit tags provided.", "is_refined": true }, { "subclaim": "During the embolization procedure, a small amount of glue and lipiodol emulsion was embolized to the lungs.", "support_label": "not_supported", "original_label": "not_supported", "reasoning_audit": "No explicit tags provided.", "is_refined": true }, { "subclaim": "The embolization occurred through an unrecognized intrahepatic portosystemic fistula.", "support_label": "not_supported", "original_label": "not_supported", "reasoning_audit": "No explicit tags provided.", "is_refined": true }, { "subclaim": "The patient remained clinically stable.", "support_label": "supported", "is_refined": false }, { "subclaim": "The patient underwent the planned hepatic resection after 4 weeks.", "support_label": "not_supported", "original_label": "not_supported", "reasoning_audit": "No explicit tags provided.", "is_refined": true }, { "subclaim": "The postoperative course was uneventful.", "support_label": "not_supported", "original_label": "not_supported", "reasoning_audit": "No explicit tags provided.", "is_refined": true } ] }, { "id": "multiclinsum_test_2467_en.txt", "fulltext": "The patient was a 70-year-old Japanese man (172.0 cm tall, weighing 68.0 kg, body\nmass index 23.0 kg/m2) who had smoked 20 cigarettes a day for 47 years\nuntil 5 years ago. He was under treatment and follow-up for essential hypertension,\ndyslipidemia and chronic kidney disease, and his blood pressure and lipid levels\nwere well controlled with administration of 40 mg of olmesartan medoxomil (Olm) and\n5 mg of atorvastatin calcium hydrate. His renal function was stable. The patient\npresented with nasal discharge, malaise and a mild cough, and tested positive for\nSARS-CoV-2 by the polymerase chain reaction (PCR) test three days after coming in\nextended contact with a colleague who was also diagnosed with SARS-CoV-2. Since he\nhad many risk factors for disease aggravation, he was urgently admitted to our\nhospital (Day 1) the day after symptom onset and confirmation of the diagnosis.\nAt admission, his body temperature was 36.4 °C, blood pressure was 185/72 mm Hg,\npulse was 86 beats/min, respiratory rate was 20 beats/min and peripheral oxygen\nsaturation on pulse oximetry (SpO2) was 97.0%. Laboratory findings at\nthis time showed lymphocyte depletion and coagulation abnormalities [lymphocytes\n8.5%, fibrinogen 518 mg/dL, fibrinogen degradation products 5.26 μg/mL and D-dimer\n(D-D) 1.68 μg/mL] . In addition, iron deficiency anemia was observed (he was\nscheduled for close examination of the gastrointestinal tract after COVID-19 was\ncured), and hence, it was difficult to evaluate the clinical implication of the\nobserved low ferritin level . CT showed emphysematous changes in the lung field. Ground\nglass opacities with neither a crazy-paving pattern nor consolidation was found\nbelow the dorsal pleura of the upper right lobe, and the total CT score was 1/25\npoints (upper right lobe 1/5 points, middle lobe 0/5 points, lower right lobe 0/5\npoints, upper left lobe 0/5 points and lower left lobe 0/5 points), based on the\nscoring system described by Pan et al. In addition, fibrosis, subpleural lines, the reversed “halo sign”, pleural\neffusion and lymphadenopathy were not observed. It was considered to be a typical\nfindings of early mild COVID-19 pneumonia .\nAlthough no decrease in SpO2 was observed, administration of favipiravir\n(Fav) 3600 mg daily was started from the evening of the same day, due to the\npresence of mild pneumonia as seen on CT and the presence of multiple comorbidities.\nIn addition, since SpO2 decreased a little the following day, 1 L/min\noxygen administration via a nasal cannula was also started. Weakness and a decreased\nlevel of consciousness (tendency to somnolence) appeared from the early morning of\nDay 2, but a neurologist ruled out stroke. Since somnolence and weakness were\nconsidered as side effects of Fav, the drug was discontinued on the evening of Day\n2, and his symptoms improved by the morning of Day 3. Thereafter, since his\ntemperature increased again, the frequency of administration of acetaminophen 500 mg\nwas increased from 0 to 3 times a day. In addition, his CRP level increased and\nSpO2 decreased, requiring an increase in oxygen flow rate from 1 to\n3 L/min by nasal cannula. CT performed on Day 4 showed slight deterioration in the\npneumonia. The total CT score was 2/25 points (ground-glass opacities only below the\ndorsal pleura of the upper right lobe) . Therefore, 200 mg of remdesivir\n(Rem) was administered on Day 4, with 100 mg daily being administered from Day 5\nuntil Day 10, for a total of seven days . On Day 7, blood gas data under\nadministration of 4 L/min oxygen by nasal cannula showed that the alveolar-arterial\noxygen difference (A-aDO2) had increased to 122.1 mm Hg , indicating an\nimbalance between ventilation and blood flow. However, no pulmonary hypertension was\nobserved on electrocardiogram or echocardiography. Furthermore, since a tendency of\nincreasing D-D levels was also observed , the combination of nafamostat\nmesylate (Naf) 100 mg daily by continuous intravenous infusion and dexamethasone\n(Dex) 6 mg daily was administered for four days from Day 7 . The treatment was remarkably\neffective, resulting in fever reduction and a decrease in CRP and D-D levels (, c and d). On Day\n10, oxygen administration could be discontinued, and at the same time , his blood\npressure control improved . By Day 13, A-aDO2 had also significantly improved\nto 33.2 mm Hg without supplementary oxygen , and CT showed a tendency for\nimprovement in pneumonia. The total CT score at this time was still 2/25 points\n(ground-glass opacities only below the dorsal pleura of the upper right lobe) .\nFor blood pressure control during the course of his hospitalization, continuous\nintravenous infusion of pernidipine (4-9 mg/h) was performed for two days when oral\nintake was difficult due to the decreased consciousness level, and from day 4, Olm\n40 mg and nifedipine 20 mg were administered in combination. With the treatment of\nCOVID-19, his blood pressure gradually stabilized, and the dose of nifedipine was\nreduced from Day 14 to 10 mg, and nifedipine was discontinued from Day 19 .\nIt took some more time for SpO2 to stabilize, but it eventually improved\nand the patient was discharged on Day 21 .", "summary": "A 70-year-old Japanese man with essential hypertension, dyslipidemia, chronic kidney disease and emphysema was hospitalized with the novel coronavirus disease. He had hypoxemia that was disproportionate to the severity of pneumonia indicated by computed tomography (CT), along with coagulation abnormalities. We speculated that there was a high possibility that he had developed ventilation and blood flow imbalance due to pulmonary intravascular coagulopathy (PIC) or hypoxic pulmonary vasoconstriction (HPV). In this case, early, short-term combination therapy with remdesivir, nafamostat mesylate and low-dose dexamethasone (Dex) was successful.", "subclaim_evaluations": [ { "subclaim": "The patient is a 70-year-old Japanese man.", "support_label": "supported", "is_refined": false }, { "subclaim": "The patient has essential hypertension.", "support_label": "supported", "is_refined": false }, { "subclaim": "The patient has dyslipidemia.", "support_label": "supported", "is_refined": false }, { "subclaim": "The patient has chronic kidney disease.", "support_label": "supported", "is_refined": false }, { "subclaim": "The patient has emphysema.", "support_label": "supported", "is_refined": false }, { "subclaim": "The patient was hospitalized with the novel coronavirus disease.", "support_label": "supported", "is_refined": false }, { "subclaim": "The patient had hypoxemia.", "support_label": "supported", "is_refined": false }, { "subclaim": "The hypoxemia was disproportionate to the severity of pneumonia indicated by CT.", "support_label": "supported", "is_refined": false }, { "subclaim": "The patient had coagulation abnormalities.", "support_label": "supported", "is_refined": false }, { "subclaim": "The clinicians speculated that the patient had a high possibility of developing ventilation and blood flow imbalance.", "support_label": "supported", "is_refined": false }, { "subclaim": "The clinicians speculated that the imbalance was due to pulmonary intravascular coagulopathy.", "support_label": "not_supported", "original_label": "not_supported", "reasoning_audit": "No explicit tags provided.", "is_refined": true }, { "subclaim": "The clinicians speculated that the imbalance was due to hypoxic pulmonary vasoconstriction.", "support_label": "not_supported", "original_label": "not_supported", "reasoning_audit": "No explicit tags provided.", "is_refined": true }, { "subclaim": "The patient received early, short-term combination therapy.", "support_label": "not_supported", "original_label": "not_supported", "reasoning_audit": "No explicit tags provided.", "is_refined": true }, { "subclaim": "The therapy included remdesivir.", "support_label": "supported", "is_refined": false }, { "subclaim": "The therapy included nafamostat mesylate.", "support_label": "supported", "is_refined": false }, { "subclaim": "The therapy included low-dose dexamethasone.", "support_label": "supported", "is_refined": false }, { "subclaim": "The combination therapy was successful.", "support_label": "supported", "is_refined": false } ] }, { "id": "multiclinsum_test_493_en.txt", "fulltext": "A 62-year old male patient had a robot-assisted laparoscopic prostatectomy in August 2014 for a Gleason 4 + 3 multifocal adenocarcinoma with tertiary grade 5 disease and extraprostatic extension (pT3aN0Mx). The pre-operative PSA was 5.3 μg/L and the post-operative PSA was unchanged at 5.63 μg/L, despite negative surgical margins . The PSA, 6 months post-operatively, had increased to 10.06 μg/L. Pelvic MRI showed no local recurrence or residual prostatic tissue and a bone scan was also negative. Androgen deprivation therapy (ADT) was commenced with a subsequent fall in PSA to < 0.02 μg/L, but it was discontinued after a year due to side effects.\nSerum PSA tests were undertaken regularly . 4.5 years post-operatively, the PSA increased to 2.33 μg/L and staging CT and whole-body bone scintigram showed no evidence of metastatic disease.\nFive years after prostatectomy, the PSA reached 10.6 μg/L, and the patient underwent a [68Ga]Ga-THP-PSMA PET/CT using a cold kit PSMA formulation [–]. Sixty minutes after intravenous injection of 204 MBq of tracer a [68Ga]Ga-THP-PSMA PET/CT was acquired from proximal thighs to skull base on a GE Discovery 690 PET-CT scanner (GE Healthcare, Chicago, USA) according to current guidelines (4 min per bed position with 23% overlap and axial field of view of 16 cm). A low-dose unenhanced CT scan (120 kVp, 0.5 s rotation time, 3.75 mm slices, Noise Index 45, 10–180 mA) was performed for attenuation correction and localization purposes. PET reconstructions included corrections for radiotracer decay, attenuation, modeled scatter, randoms and dead-time, both for time-of-flight (TOF ordered subset expectation maximisation with 24 subsets and 2 iterations) and scatter-limit correction series. The PET/CT showed increased focal uptake in the right mid-cranial fossa, with no focal uptake in the rest of the body. The differential considered at this point was a meningioma, glioma or a prostate metastasis, all known to express PSMA [–]. The patient had no neurological symptoms at the time of presentation.\nA subsequent contrast-enhanced MRI head showed a well-demarcated enhancing dural-based lesion in the floor of the right middle cranial fossa, projecting into the right temporal lobe, with surrounding T2 hyperintense changes in the right temporal lobe, believed to be extra-axial on MRI. The lesion was thought initially to represent a meningioma, both on the [68Ga]Ga-THP-PSMA PET/CT (SUVmax TOF = 6.2) and contrast-enhanced MRI, although the PET/CT had raised the suspicion of a prostate cancer metastasis given its unusually intense uptake .\nAs uncertainty remained between the two possible diagnoses (meningioma or prostate cancer metastasis) in the neuro-oncology multidisciplinary team meeting, the patient was referred for a neurosurgical opinion, which advised the lesion’s surgical resection and dexamethasone 4 mg bd, to reduce surrounding oedema. A second MRI head, performed 1 month later for pre-surgical planning, confirmed a 23 × 18 mm solitary tumour with surrounding oedema in the anterior part of the right inferior temporal gyrus. The tumour contained heterogeneous low and high areas of T2 signal, patchy heterogeneous contrast enhancement and dural extension to the brain surface inferiorly. The second MRI suggested that the lesion was intra-axial. The contrast-enhanced post-operative MRI head showed complete resection of the tumour with a reduction in serum PSA to 2.93 μg/L. The histopathology report confirmed an intra-axial right temporal lobe metastatic prostatic adenocarcinoma with dural extension and intense PSA and PSAP staining. Three months after neurosurgery the patient had recovered well with only mild neurological deficit (left foot drop). Surveillance MRI showed no intracranial mass or abnormal contrast enhancement to indicate residual or recurrent tumour and only expected post-operative encephalomalacia in the anterior inferior part of the right temporal lobe. The serum PSA remained elevated (2.28 μg/l). Currently, the patient is followed up with 3-monthly MRIs and PSA monitoring. ADT has not been restarted. Although the post-operative MRI head showed complete resection, the fact that histopathology documented dural involvement could explain the elevated PSA after surgery and potential presence of residual microscopic meningeal disease. The patient is currently asymptomatic, but he will undergo further PSMA PET/CT if the PSA continues to rise.", "summary": "We report the case of a prostate cancer patient presenting 5 years after robot-assisted laparoscopic prostatectomy with biochemical recurrence, no neurological symptoms, and in the absence of metastatic lesions in the body on conventional imaging. A solitary cerebral metastasis was detected using", "subclaim_evaluations": [ { "subclaim": "The patient is a prostate cancer patient.", "support_label": "supported", "is_refined": false }, { "subclaim": "The patient had a robot-assisted laparoscopic prostatectomy.", "support_label": "supported", "is_refined": false }, { "subclaim": "The patient had biochemical recurrence.", "support_label": "supported", "is_refined": false }, { "subclaim": "The recurrence occurred 5 years after the prostatectomy.", "support_label": "supported", "is_refined": false }, { "subclaim": "The patient had no neurological symptoms.", "support_label": "supported", "is_refined": false }, { "subclaim": "There were no metastatic lesions in the body on conventional imaging.", "support_label": "supported", "is_refined": false }, { "subclaim": "A solitary cerebral metastasis was detected.", "support_label": "supported", "is_refined": false } ] }, { "id": "multiclinsum_test_2451_en.txt", "fulltext": "A 59-year-old man had a history of four years of paroxysmal AF. He was normotensive and euglycemic. Due to recurrent symptomatic AF episodes and subsequent failure of antiarrhythmic drugs, he underwent a cryoballoon ablation of the PV. Under local anesthesia, His and coronary sinus catheter were inserted via the left groin. Cryoconsole was switched on for cryotherapy, but it displayed “low refrigerant level”. After trans-septal puncture, angiogram of the left atrium revealed left-sided common PV ostia of 29.4 mm, right superior PV of 24 mm, and right inferior PV of 14 mm. Successful ablation of all other PVs except for the right inferior PV were performed using six application cycles of four minutes each with 28 mm cryoballoon (Arctic FrontTM, Medtronic; CB, Medtronic, Minneapolis, MN, USA). Then cryoballoon was positioned to the ostium of right inferior PV. Vein occlusion was monitored for cryoballoon-to-PV contact by observing during the injection of a 50%-diluted contrast medium distally into the PV. This is graded on a 1 to 4 scale, with 1 being minimum occlusion and 4 being complete occlusion. For this PV, the grade of occlusion obtained was 4/4 . Freezing was started. In spite of waiting for more than 60 seconds, the minimum temperature did not cross beyond -34°C. Special maneuvers as “pull-down technique” and “hockey stick technique” were tried, without any success (11). The application was stopped considering the nonoptimal temperature (9). The cryoballoon was repositioned for better PV contact, reverified by diluted contrast injection to be 4/4 of grade of occlusion. However, the temperature again did not cross beyond -30°C. The application was again stopped at 60 seconds. After optimal positioning cryoablation was reattempted. Surprisingly, again, the temperature did not cross beyond -28°C. We were intrigued for the reason behind this. Afterwards, a final try with cryoballoon was thought for before switching to cryocatheter for AchieveTM (Medtronic Inc.) guided touchups. Finally, after observing the 4/4 occlusion grade, freezing was restarted for the third time. To our disappointment even after 60 seconds, the temperature was still hovering around -9°C. The moment the freezing application was to be stopped, the cryoconsole screen flashed, “The pressure is low in the system. Ensure the refrigerant tank is open”. Ultimately, the refrigerant cylinder was changed. Cryoablation was reinitiated after ensuring the 4/4 occlusion and optimal positioning. Minimum ablation temperature of -47°C was reached with acute successful isolation of PVs . We faced similar situation described above three times in a span of nine months for different PVs. After communicating about this problem to Medtronic’s local representative, data was retrospectively collected from cryoconsole for further investigations. The flow of the gas through the umbilical (displayed at a cryoconsole) was measured and investigated in the data files. However, the analysis showed no known technical issues.\nIf nonoptimal temperature is obtained in spite of good grade of occlusion of cryoballoon and optimal positioning, early change of a refrigerant cylinder ought to be considered in case of “low refrigerant level” cryoconsole display. Earlier change may be considered in spite of absence of the system notice, stating “The pressure is low in the system”, to decrease the procedure time and unnecessary radiation exposure. Retrospectively, it may be suggested to the device manufacturer for use of better pressure-sensitive refrigerant cylinder valve or earlier system notification for change of the refrigerant cylinder.", "summary": "At the start of the procedure, the cryoconsole displayed \"low refrigerant level\". After a few cycles of successful cryoballoon applications, for a fresh application for a new PV, the optimal temperature was not obtained in spite of obtaining good grade of occlusion and ostial positioning for right inferior pulmonary vein (RIPV). Later, immediately after changing the refrigerant cylinder, suitable temperature was obtained. We faced this situation thrice in a span of eight months.", "subclaim_evaluations": [ { "subclaim": "The cryoconsole displayed 'low refrigerant level' at the start of the procedure.", "support_label": "supported", "is_refined": false }, { "subclaim": "Successful cryoballoon applications were performed before the issue occurred.", "support_label": "supported", "is_refined": false }, { "subclaim": "The issue occurred during a fresh application for a new pulmonary vein.", "support_label": "supported", "is_refined": false }, { "subclaim": "The optimal temperature was not obtained during the application.", "support_label": "supported", "is_refined": false }, { "subclaim": "Good grade of occlusion was achieved during the application.", "support_label": "supported", "is_refined": false }, { "subclaim": "Ostial positioning for the right inferior pulmonary vein was adequate.", "support_label": "supported", "is_refined": false }, { "subclaim": "The refrigerant cylinder was changed.", "support_label": "supported", "is_refined": false }, { "subclaim": "Suitable temperature was obtained after changing the refrigerant cylinder.", "support_label": "supported", "is_refined": false }, { "subclaim": "This situation occurred three times in eight months.", "support_label": "not_supported", "original_label": "not_supported", "reasoning_audit": "No explicit tags provided.", "is_refined": true } ] }, { "id": "multiclinsum_test_998_en.txt", "fulltext": "The patient was a 43-year-old Japanese woman who underwent 70 Gy heavy-particle radiotherapy administered as 5 fractions of 14 Gy for a right choroidal malignant melanoma (T3a, N0, M0 clinical-stage IIB according to the 8th edition of the International Union Against Cancer classification) . Positron emission tomography-computed tomography (PET-CT) performed post-treatment revealed no abnormal accumulation of 2-deoxy-2-(fluorine-18) fluoro-d-glucose, and the complete response was recorded . PET-CT examination was subsequently performed regularly every 6 months, and no recurrence was noted up to 4 years after treatment, when contrast accumulation (maximum standardized uptake value 10.9) was observed on the posterior wall of the stomach .\nGastrointestinal endoscopic examination revealed a smooth, protruding lesion on the wall of the greater curvature of the stomach . Endoscopic ultrasonography (EUS) revealed extramural growth of a hypoechoic tumor with the presence of blood flow inside, on the posterior wall of the stomach that was approximately 2.2 × 2.0 cm in size . CT showed a mass with contrast enhancement in contact with the stomach wall . Based on the imaging findings, a gastrointestinal stromal tumor (GIST) at the posterior wall of the lower gastric corpus with extramural growth was suspected. Therefore, the patient was referred to our hospital for treatment.\nLaparoscopic surgery was performed under general anesthesia. A black-pigmented tumor originating from the body of the pancreas was discovered to be in contact with the posterior wall of the stomach , but continuity was not observed. Based on the intraoperative findings, metastasis of the malignant choroidal melanoma to the pancreas was diagnosed. Since no other lesions were discovered in the abdominal cavity, it was determined that resection would be possible, and laparoscopic pancreatic tail resection was performed.\nThe resected tumor comprised a single black nodule with a long-axis diameter of 27 mm . Hematoxylin and eosin staining revealed spindle cells with melanin pigment production . Immunohistological examination showed positive signals for the S100 protein, HNB-45, and Melan A, confirming the diagnosis . On postoperative day 20, a grade IIIa pancreatic fistula (Clavien–Dindo classification version 2) developed, but amelioration was achieved using conservative treatment. The patient was discharged on postoperative day 50.\nAdministration of 3 mg/kg nivolumab was initiated as adjuvant chemotherapy 2 months after surgery, but 2 months later multiple lung metastases were detected by CT. Therefore, administration of 3 mg/kg ipilimumab was initiated. Following the first dose, the patient developed colitis as an immune-related adverse event and grade 3 diarrhea (based on the Common Terminology Criteria for Adverse Events version 5.0 classification), the latter of which was ameliorated by oral administration of 30 mg prednisolone. There was an outbreak of dermatitis, which was also judged to be an immune-related adverse event, and the administration of ipilimumab was discontinued. Two courses of 800 mg/m2 dacarbazine were administered 12 months postoperatively, but the treatment was discontinued due to metastasis to the left kidney. Nivolumab administration resumed 28 months after surgery. The patient was alive after 17 courses of nivolumab without symptoms or exacerbation of the lesion.", "summary": "A 43-year-old Japanese woman underwent 70 Gy heavy-particle radiotherapy for a right choroidal malignant melanoma. Positron emission tomography-computed tomography examination was performed 4 years after treatment, when contrast accumulation was observed on the posterior wall of the stomach. Endoscopic ultrasonography and computed tomography showed a mass with contrast enhancement in contact with the stomach wall. Based on the imaging findings, a gastrointestinal stromal tumor of the posterior wall of the lower gastric corpus with extramural growth was suspected. Laparoscopic surgery was performed under general anesthesia. A black-pigmented tumor originating from the pancreas was discovered. Following an intraoperative diagnosis of metastasis of malignant melanoma, a laparoscopic distal pancreatectomy was performed. The pathological diagnosis was pancreatic metastasis of malignant melanoma. The patient was treated with adjuvant immune checkpoint inhibitors and chemotherapy after surgery, which led to long-term survival.", "subclaim_evaluations": [ { "subclaim": "The patient is a 43-year-old Japanese woman.", "support_label": "supported", "is_refined": false }, { "subclaim": "She underwent 70 Gy heavy-particle radiotherapy.", "support_label": "supported", "is_refined": false }, { "subclaim": "The radiotherapy was for a right choroidal malignant melanoma.", "support_label": "supported", "is_refined": false }, { "subclaim": "A positron emission tomography-computed tomography examination was performed 4 years after treatment.", "support_label": "supported", "is_refined": false }, { "subclaim": "Contrast accumulation was observed on the posterior wall of the stomach.", "support_label": "supported", "is_refined": false }, { "subclaim": "Endoscopic ultrasonography showed a mass with contrast enhancement in contact with the stomach wall.", "support_label": "supported", "is_refined": false }, { "subclaim": "A gastrointestinal stromal tumor of the posterior wall of the lower gastric corpus with extramural growth was suspected.", "support_label": "supported", "is_refined": false }, { "subclaim": "Laparoscopic surgery was performed under general anesthesia.", "support_label": "supported", "is_refined": false }, { "subclaim": "A black-pigmented tumor originating from the pancreas was discovered.", "support_label": "supported", "is_refined": false }, { "subclaim": "An intraoperative diagnosis of metastasis of malignant melanoma was made.", "support_label": "supported", "is_refined": false }, { "subclaim": "A laparoscopic distal pancreatectomy was performed.", "support_label": "supported", "is_refined": false }, { "subclaim": "The pathological diagnosis was pancreatic metastasis of malignant melanoma.", "support_label": "supported", "is_refined": false }, { "subclaim": "The patient was treated with adjuvant immune checkpoint inhibitors after surgery.", "support_label": "supported", "is_refined": false }, { "subclaim": "The patient was treated with chemotherapy after surgery.", "support_label": "supported", "is_refined": false }, { "subclaim": "The treatment led to long-term survival.", "support_label": "supported", "is_refined": false } ] }, { "id": "multiclinsum_test_2906_en.txt", "fulltext": "A 28-year-old Caucasian Greek woman presented to the emergency department after sustaining an injury to her right knee during dancing. The mechanism of her injury compromised vigorous internal rotation of the femur on the tibia with the knee in flexion. She complained of mild pain in both the medial and lateral aspects of her knee joint. Her right knee was locked in 35° of flexion.\nPhysical examination demonstrated negative Lachman-Noulis and anterior drawer tests. Clicks or catches were not detected by palpation during flexion, extension, and rotary motions of her knee joint. There was tenderness in her medial and lateral joint line. Results of standard anteroposterior and lateral roentgenograms were normal. A magnetic resonance imaging (MRI) evaluation demonstrated the tears in both menisci of the right knee , while the anterior and posterior cruciate ligaments were found to be intact .\nOur patient had no relevant medical history. Her physical examination and laboratory tests were unremarkable. No diseases of the connective tissue or other deficiency of the ligaments were detected.\nShe underwent a knee arthroscopy in the next 24 hours, and the diagnosis of combined injury of bicompartmental bucket-handle tears with an intact anterior cruciate ligament was confirmed . Arthroscopic evaluation also revealed a discoid lateral meniscus. Moreover, a grade III chondral lesion (graded on the Outerbridge classification), less than 1 cm2 in size, was detected on the medial femoral condyle . A partial medial and lateral meniscectomy was then performed. The decision was made because of the discoid lateral meniscus and the quality of the ruptured part of the medial meniscus. The torn tissue - approximately 40% of the mediolateral width of each meniscus - was removed. The cartilage defect was repaired by drilling therapeutic holes (approximately 0.5 to 1.0 mm in diameter) into the subchondral bone marrow space underlying the region of the cartilage lesion (microfracture technique) .\nAt our patient's follow-up examination six months after her injury, clinical tests demonstrated that her right knee was stable, had a full range of motion and had no tenderness. The functional outcome was evaluated using Lysholm scoring. At the time of her presentation to our emergency department she had a Lysholm score of 75, while six months after her injury, her Lysholm score had increased to 85 . She was satisfied with the outcome of the operation and returned to her pre-injury activities.", "summary": "A 28-year-old Caucasian Greek woman presented to the emergency department after sustaining an injury to her right knee during dancing. An MRI evaluation demonstrated tears in both menisci of the right knee, while the anterior and posterior cruciate ligaments were found to be intact. A partial medial and lateral meniscectomy was then performed. At a follow-up examination six months after her injury, clinical tests demonstrated that our patient's right knee was stable, had a full range of motion and had no tenderness. She was satisfied with the outcome of the operation and returned to her pre-injury activities.", "subclaim_evaluations": [ { "subclaim": "The patient is a 28-year-old woman.", "support_label": "supported", "is_refined": false }, { "subclaim": "The patient is of Caucasian Greek descent.", "support_label": "supported", "is_refined": false }, { "subclaim": "The patient sustained an injury to her right knee.", "support_label": "supported", "is_refined": false }, { "subclaim": "The injury occurred during dancing.", "support_label": "supported", "is_refined": false }, { "subclaim": "An MRI was performed.", "support_label": "supported", "is_refined": false }, { "subclaim": "The MRI showed tears in both menisci of the right knee.", "support_label": "supported", "is_refined": false }, { "subclaim": "The anterior cruciate ligament was intact.", "support_label": "supported", "is_refined": false }, { "subclaim": "The posterior cruciate ligament was intact.", "support_label": "supported", "is_refined": false }, { "subclaim": "A partial medial meniscectomy was performed.", "support_label": "supported", "is_refined": false }, { "subclaim": "A partial lateral meniscectomy was performed.", "support_label": "supported", "is_refined": false }, { "subclaim": "A follow-up examination was conducted six months after the injury.", "support_label": "supported", "is_refined": false }, { "subclaim": "The right knee was stable at the six-month follow-up.", "support_label": "supported", "is_refined": false }, { "subclaim": "The right knee had a full range of motion at the six-month follow-up.", "support_label": "supported", "is_refined": false }, { "subclaim": "There was no tenderness in the right knee at the six-month follow-up.", "support_label": "supported", "is_refined": false }, { "subclaim": "The patient was satisfied with the outcome of the operation.", "support_label": "supported", "is_refined": false }, { "subclaim": "The patient returned to her pre-injury activities.", "support_label": "supported", "is_refined": false } ] }, { "id": "multiclinsum_test_3115_en.txt", "fulltext": "A 56-year-old postmenopausal woman presented with a history of intermittent mastalgia, mild lumpiness, and clear nipple discharge of the right breast, which started a year ago. She has a previous known history of right breast intraductal papilloma without atypia 8 years ago, for which she refused the intervention at that time. Her mammogram two years ago was reassuring.\n\nAn ultrasound scan revealed a highly suspicious mass at the 2 o’clock position of the right breast periareolar area, measuring 17 mm, with a hypoechoic dilated duct measuring over 50 mm in length and 3.4 mm in diameter at the medial aspect of the right nipple. The axilla appeared normal on the ultrasound scan.\n\nUpon comparison of mammograms from eight years ago and two years ago, the lesion was identified as a new development. An ultrasound-guided core biopsy of the right breast mass was performed. The histopathological evaluation revealed a Grade II Invasive Ductal Carcinoma.\n\nAfter a multidisciplinary team meeting, a Magnetic Resonance Imaging (MRI) and breast tomosynthesis were ordered to assess the disease extent. The known malignancy of the upper inner quadrant was identified, measuring 26 mm in the longest dimension. The MRI study identified an anterior extension accounting for an overall extent of 31 mm.\n\nA SS reflector was placed at the site of the tumour under ultrasound guidance. No immediate complications were noted. Post-insertion mammogram has been obtained.\n\nImaging revealed that the scout was successfully placed in the lesion.\n\nTwo days later, the patient presented to the breast clinic complaining of severe stabbing pain in the right nipple. An ultrasound and mammogram scan revealed that the scout had migrated from the site of the cancer into the duct at the tip of the nipple.\n\nUnder local anaesthesia, a small incision was made on the skin over the tip of the scout, and it was removed. The patient visited the clinic the next day and reported reduced pain and discomfort since the scout was removed.\n\nThe patient declined to have another SS reflector due to distress during the initial procedure. The decision has been made to proceed with skin marker-guided wide local excision, which she has had. Postoperative histopathological evaluation showed 27 mm grade 2 invasive ductal carcinoma (IDC) no special type, with no associated ductal carcinoma in situ, which is completely excised, and sentinel node biopsy was negative.", "summary": "A 56-year-old postmenopausal woman with a history of right breast intraductal papilloma which transformed to Grade II Invasive Ductal Carcinoma (IDC) has a Savi Scout reflector placed in the tumour. However, it migrated through a dilated duct and emerged at the nipple, causing severe pain. The reflector was then surgically removed, and the patient subsequently underwent wide local excision with skin marker localisation.", "subclaim_evaluations": [ { "subclaim": "The patient is a 56-year-old postmenopausal woman.", "support_label": "supported", "is_refined": false }, { "subclaim": "She has a history of right breast intraductal papilloma.", "support_label": "supported", "is_refined": false }, { "subclaim": "The intraductal papilloma transformed to Grade II Invasive Ductal Carcinoma.", "support_label": "not_supported", "original_label": "not_supported", "reasoning_audit": "No explicit tags provided.", "is_refined": true }, { "subclaim": "A Savi Scout reflector was placed in the tumour.", "support_label": "supported", "is_refined": false }, { "subclaim": "The reflector migrated through a dilated duct.", "support_label": "supported", "is_refined": false }, { "subclaim": "The reflector emerged at the nipple.", "support_label": "supported", "is_refined": false }, { "subclaim": "The reflector caused severe pain.", "support_label": "supported", "is_refined": false }, { "subclaim": "The reflector was surgically removed.", "support_label": "supported", "is_refined": false }, { "subclaim": "The patient underwent wide local excision.", "support_label": "supported", "is_refined": false }, { "subclaim": "Skin marker localisation was used during the excision.", "support_label": "supported", "is_refined": false } ] }, { "id": "multiclinsum_test_2908_en.txt", "fulltext": "Our patient was initially referred to another hospital with mild head injury when he was 8 years old. An intra-axial tumor located in the right insular cortex was incidentally detected on MRI. Surgical resection was waived and followed-up for 10 years until the patient was 18 years old because of slowly growing tumor without symptoms. At the end of the observation period, the tumor size was measured to be one and a half times the diameter measured on the first MRI scan. After the end of the follow-up period, he visited our hospital for intensive examination and treatment.\nThe patient had no neurological deficit. Computed tomography (CT) imaging showed a low-density lesion with no calcification located in the right insular cortex . T1-weighted MRI demonstrated a hypointense lesion in the right insular cortex . T2-weighted MRI showed a hyperintense lesion that corresponded with the hypointensity on the T1-weighted image . T1-weighted MRI with gadolinium administration did not show any enhanced lesions [Figure and ]. Arterial spin labeling study suggested decreased blood flow at the lesion .\nThe lesion located in the right insular cortex demonstrated gradual growth for 10 years [Figure -]. The change in lesion volume was assessed using polygonal tracing with fusion. Fluid-attenuated inversion recovery (FLAIR) signals were assessed using the DICOM image viewer OsiriX (®) (v. 7.0; Pixmeo SARL, Bernex, Switzerland) by slice-by-slice region of interest tracings. The growth rate of this lesion was found to be almost directly proportional to time .\nIn order to remove the lesion and obtain histopathological diagnosis, an awake craniotomy was performed using cortical and subcortical stimulation mapping with a bipolar direct electrical stimulator at 3.5 mA/60 Hz biphasic current to monitor motor and somatosensory response, speech or language difficulties, and other higher brain functions. An anarthria was induced by stimulation of the ventral precentral gyrus . Tumor resection was performed via a transopercular approach. Intraoperatively, the nature of the tumor was gray, soft, and jelly-like tissue with clear boundaries. Fiber structures in the peripheral zone were relatively well-defined and we promoted excision of the tumor using an ultrasonic surgical aspirator. A postoperative MRI showed gross total resection of the tumor . Postoperative course was uneventful without neurological deficits. No recurrence was recognized postoperatively for 12 months.\nHistological examination of the hypointense area on T1-weighted MRI showed multiple cystic structures with myxomatous background and proliferation of oligodendroglia-like cells with oval nuclei in the wall of the cystic spaces . Neuronal elements featuring “floating neurons” were observed, indicating a glioneuronal lesion within the cystic cavity . Immunohistochemical analysis revealed intense positive staining for Olig2, S-100 and synaptophysin, and less reactivity for IDH-1 . The Ki-67 staining index (SI) was 1% . A combined deletion of 1p and 19q chromosomes was absent. The histological diagnosis was WHO grade I DNET.", "summary": "We report the first DNET case with the growth rate analyzed in the natural course of development for a period of 10 years. The patient was a right-handed man who was initially referred to another hospital with mild head injury when he was 8 years old. A tumor located in the right insular cortex was incidentally detected on magnetic resonance imaging (MRI) and followed-up with annual MRI for 10 years.", "subclaim_evaluations": [ { "subclaim": "This is the first reported case of DNET with growth rate analyzed over 10 years.", "support_label": "not_supported", "original_label": "not_supported", "reasoning_audit": "No explicit tags provided.", "is_refined": true }, { "subclaim": "The patient was a right-handed man.", "support_label": "not_supported", "original_label": "not_supported", "reasoning_audit": "No explicit tags provided.", "is_refined": true }, { "subclaim": "He was initially referred to another hospital at age 8 with mild head injury.", "support_label": "supported", "is_refined": false }, { "subclaim": "A tumor was incidentally detected in the right insular cortex on MRI.", "support_label": "supported", "is_refined": false }, { "subclaim": "The tumor was followed up with annual MRI for 10 years.", "support_label": "not_supported", "original_label": "not_supported", "reasoning_audit": "No explicit tags provided.", "is_refined": true } ] }, { "id": "multiclinsum_test_1722_en.txt", "fulltext": "A 10-month-old child, assigned as female at birth, resident in the countryside of the Northeast region of Brazil, was referred to our team for genetic assessment due to genital ambiguity late recognized. Pregnancy and delivery were uneventful. Parents reported a clitoris enlargement and gonadal descent when the child was 30 days old, at the end of minipuberty. Afterward, they decided to rear him as a boy despite the maintenance of female legal sex. The patient is the second child in a consanguineous marriage (double first cousins once removed), with no recurrence in the family .\nUpon physical examination there was a phallus measuring 25 mm × 10 mm, palpable gonads at labioscrotal folds (1 cm3 left-sided and 0.5 cm3 right-sided), and an urogenital sinus with a perineal opening . As these clinical findings indicate male prenatal under- instead of female hyper- virilization we assumed that Quigley type 4 was the best classification for the ambiguous genitalia. The karyotype of peripheral lymphocytes was 46,XY. Basal FSH and LH levels were normal (1.32 mUl/mL and 0.34 mUI/mL, respectively) while those for testosterone were low (< 8 ng/dL). Abdominal ultrasound showed no Mullerian derivative structures.\nThe etiologic investigation included androgen receptor (RA – OMIM * 313700), steroid 5α-reductase 2 (SRD5A2 – OMIM * 607306), nuclear receptor subfamily 5 group A member 1 (NR5A1– OMIM * 184757), and HSD17B3 genes sequencing and predictive analyzes (Additional file ).\nSequencing studies showed a novel homozygous c.785G > T nucleotide change in exon 10 of the HSD17B3 gene (Additional file ), which was inherited from both heterozygous parents. The c.785G > T substitution leads to the replacement of glycine by valine in residue 262 (p.Gly262Val).\nGlycine 262 is a highly conserved residue (Additional file ) and the comparison between them did not reveal changes on the protein internal contacts (Additional file ). Four out of six predictive analyzes were compatible with a damaging missense variant and indicated that valine 262 destabilizes the protein structure (Additional file ).", "summary": "We report on a child presenting severe ambiguous genitalia. Due to access constraints, specialized care did not start until the child was 10 months old. Parents are consanguineous and were born in an area of high isonymy that is a cluster for rare recessive diseases. A new homozygous missense variant c.785G > T was found in exon 10 of the HSD17B3 gene.", "subclaim_evaluations": [ { "subclaim": "The child presented with severe ambiguous genitalia.", "support_label": "supported", "is_refined": false }, { "subclaim": "Specialized care did not start until the child was 10 months old.", "support_label": "supported", "is_refined": false }, { "subclaim": "The parents are consanguineous.", "support_label": "supported", "is_refined": false }, { "subclaim": "The parents were born in an area of high isonymy.", "support_label": "supported", "is_refined": false }, { "subclaim": "The area is a cluster for rare recessive diseases.", "support_label": "not_supported", "original_label": "not_supported", "reasoning_audit": "No explicit tags provided.", "is_refined": true }, { "subclaim": "A new homozygous missense variant c.785G > T was found.", "support_label": "supported", "is_refined": false }, { "subclaim": "The variant was found in exon 10 of the HSD17B3 gene.", "support_label": "supported", "is_refined": false } ] }, { "id": "multiclinsum_test_2866_en.txt", "fulltext": "A 16-year-old male of East Asian descent arrived at night via air ambulance intubated and ventilated to our Heart Attack Centre with a history that during high-intensity interval training at the gym he suffered a cardiac arrest. On site, he received three shocks for ventricular fibrillation with a return of spontaneous circulation (ROSC) after 17 min. An electrocardiogram (ECG) recorded 11 min after ROSC demonstrated marked anterolateral ST-segment elevation. An ECG recorded 116 min post-ROSC on arrival to our centre showed normalization of the ST segments . On examination, he was intubated and ventilated, invasive blood pressure was 105/75 mmHg, and his heart rate was 86 b.p.m. in sinus rhythm. His heart sounds were normal, and there were no murmurs. His chest was clear to auscultation. Bedside echocardiography demonstrated a structurally normal heart with preserved left ventricular (LV) systolic function and no regional wall motion abnormalities. Initial troponin T was 798 ng/L (0–14 ng/L) and peaked at 3073 ng/L 2 h later. His parents gave a past medical history of Kawasaki disease, but that he was not taking any medications.\nIn view of the patient's stable clinical status, the lack of persistent ST-segment elevation on the ECG, and normal echocardiogram, we did not perform emergent coronary angiography as we did not suspect an acute coronary artery occlusion. He received a 300 mg loading dose of aspirin, a 180 mg loading dose of ticagrelor and continued on 75 mg aspirin once daily, and ticagrelor 90 mg twice daily with lansoprazole 30 mg once daily. In addition to antiplatelet therapy, he received a single 2.5 mg dose of fondaparinux, bisoprolol 2.5 mg once daily, and atorvastatin 80 mg once daily. He was admitted to the adult cardiac intensive care unit where he remained stable. Coronary angiography was performed the following morning.\nKawasaki disease was diagnosed at the age of 3 months in his country of origin for which he received intravenous immunoglobulin (IVIG) therapy on day 21 of his illness. He was not treated with acetylsalicylic acid nor was he anticoagulated. Echocardiography 6 days after IVIG treatment showed an aneurysm in the left main coronary artery measuring 5.5 mm. He responded well to treatment and remained under follow-up for mild left main coronary artery dilatation.\nAged 7 years following routine surveillance echocardiography suggestive of left anterior descending artery (LAD) stenosis, he underwent invasive coronary angiography. This demonstrated a small aneurysm followed by an 80% calcific stenosis of the proximal LAD, and a chronic total occlusion (CTO) of the dominant right coronary artery (RCA). Cardiac magnetic resonance (CMR) imaging showed reversible ischaemia in the inferior, inferolateral, and anterolateral walls.\nIn 2012 aged 8 years, he underwent elective intravascular ultrasound-guided rotablation-assisted percutaneous coronary intervention (PCI) to the proximal LAD with a 3.0 mm × 18 mm Multi-Link Vision bare-metal stent (Abbott Vascular, Chicago, USA; ). This corrected the CMR perfusion abnormalities initially, but from 2015 he was lost to follow-up and was not taking any medications.\nCoronary angiography during the current admission demonstrated an unobstructed left main stem; however, the previous LAD stent was occluded with the distal vessel filling retrogradely via septal and well-developed epicardial collaterals from the RCA. The left circumflex artery (LCx) was unobstructed . There was a CTO in the RCA, as before, in the mid vessel . The likeliest explanation for his presentation was the insufficient ability of the collateral circulation to meet the metabolic demand of the heart during exercise, resulting in ischaemia and ventricular fibrillation.\nComputed tomography of the brain demonstrated no acute intracranial abnormality, and his neurological course was unremarkable.\nFollowing a local Heart Team discussion, he was transferred to a different centre with expertise in both adult and paediatric cardiology and cardiac surgery. He underwent further imaging. Computed tomography established that the internal mammary arteries (IMAs) were free of disease. CMR demonstrated increased indexed LV end-diastolic volume (118 mL/m2) and normal LV wall thickness and normal indexed LV mass with preserved global LV systolic function and no regional wall motion abnormalities at rest. There was a limited infarct in the apical anterior wall and part of the apical septum . There was inducible ischaemia in 5/7 segments of the LAD territory and 4/5 segments of the RCA territory. All segments were viable.\nAt the Heart Team meeting, it was felt that either percutaneous or surgical revascularization were suitable strategies. Two days later, the case was discussed with international colleagues and a consensus reached to revascularize him surgically with the opinion being that this would provide him with a more durable result. This was particularly pertinent in his case given the RCA CTO and previously occluded stent. Following detailed discussion with the patient and his parents, he received a left IMA to the LAD and free right IMA to the posterior descending artery. His immediate post-operative course was uncomplicated. He was discharged home 7 days after surgery on aspirin 75 mg once daily, clopidogrel 75 mg once daily, ranitidine 300 mg once daily, bisoprolol 1.25 mg once daily, atorvastatin 80 mg once daily, and paracetamol as required.\nHe was last seen in clinic in December 2019. Symptomatically, he was well and had returned to the gym but was refraining from heavy weights given his sternotomy scar. Clinical examination revealed a well-healed wound, no murmurs and a clear chest. All medications were stopped except aspirin and atorvastatin. He underwent repeat CMR in January 2020, which showed no inducible myocardial ischaemia.", "summary": "Our patient, a 16-year-old boy with Kawasaki disease, presented with cardiac arrest during exercise. Coronary angiography showed that a proximal left anterior descending artery stent implanted at the age of 8 years had occluded some time ago and his right coronary artery was also chronically occluded. He has discussed in several Heart Team meetings and with international colleagues and a consensus reached to revascularize him surgically.", "subclaim_evaluations": [ { "subclaim": "The patient is a 16-year-old boy.", "support_label": "supported", "is_refined": false }, { "subclaim": "The patient has Kawasaki disease.", "support_label": "supported", "is_refined": false }, { "subclaim": "The patient had cardiac arrest during exercise.", "support_label": "supported", "is_refined": false }, { "subclaim": "Coronary angiography showed a proximal left anterior descending artery stent.", "support_label": "supported", "is_refined": false }, { "subclaim": "The stent was implanted at the age of 8 years.", "support_label": "supported", "is_refined": false }, { "subclaim": "The stent had occluded some time ago.", "support_label": "supported", "is_refined": false }, { "subclaim": "The right coronary artery was chronically occluded.", "support_label": "supported", "is_refined": false }, { "subclaim": "The patient has discussed his case in several Heart Team meetings.", "support_label": "supported", "is_refined": false }, { "subclaim": "The patient has discussed his case with international colleagues.", "support_label": "supported", "is_refined": false }, { "subclaim": "A consensus was reached to revascularize him surgically.", "support_label": "supported", "is_refined": false } ] }, { "id": "multiclinsum_test_1100_en.txt", "fulltext": "The proband was a preterm newborn boy, the first child of non-consanguineous parents, born at 31 weeks gestation to a 44-year old father and a 43-year old mother by cesarean section. At birth, the child weighed 1,480 g, measured 44 cm in crown-to-heel length, and exhibited multiple congenital anomalies. The newborn was transferred to the Intensive Care Units (ICU) immediately after birth. His general health condition deteriorated progressively, leading to his death at 105th days after birth. The newborn had brain malformation, including ventriculomegaly and corpus callosum dysgenesis, cleft lip and palate, retrognathism, hypertelorism, clenched hands with overlapping fingers, and hypotonia. Additionally, he revealed mild heart septal hypertrophy, ambiguous genitalia, enlarged kidneys without corticomedullary differentiation, and gallbladder with tiny cystic formations . His mother had three miscarriages from previous marriages and one miscarriage with her current husband. The remaining of his family history was otherwise unremarkable.\nBoth parents signed a written informed consent and the mother signed as the legal representative for the child. Peripheral blood was obtained to isolate genomic DNA for CMA using Qiagen QIAamp® DNA Mini kit (Hilden, Germany). Karyotyping was performed in a private laboratory through conventional cell culture, harvesting, and GTG banding with a > 550 bands resolution following standard procedures . Chromosome analyses were done using Zeiss Axio Scope (Jena, Germany) and the software IKAROS® (Metasystems Corporation, Altlussheim, Germany). All laboratory procedures were carried out following international standardized protocols and consensual criteria of quality.\nThe CMA was carried out on proband and his biological parents using the GeneChip® CytoScanHD™ (Affymetrix, Santa Clara, USA) following the manufacturer’s recommendations without modifications. Chromosomal analyses were done using the Chromosome Analysis Suite (ChAS®) software (Affymetrix, Santa Clara, USA) and the CNVs found in the patient were analyzed in comparison with public databases, including Database of Genomic Variants (DGV), Database of Chromosomal Imbalance and Phenotype in Humans using Ensemble Resources (DECIPHER), and CytoScanHD™ Array Database. Furthermore, CNVs were classified according to their nature, based on [, ].\nThe proband showed a male karyotype with a large submetacentric SMC in 90% of the analyzed metaphases after counting 50 metaphase spreads. His karyotype was 47,XY,+mar[45]/46,XY[5], suggesting 10% mosaicism. The parental karyotypes and CMA results had no visible numerical or structural alterations. The proband’s CMA revealed the marker chromosome corresponded to a de novo 70.77 Mb gain at arr[GRCh37] 9p24.3q21.11(203,861_70,974,662)× 4[0.3] dn with 30% mosaicism, encompassing 286 genes, including 152 OMIM morbid genes .", "summary": "Herein, we reported a postnatal case of a newborn who died in early infancy with multiple congenital malformations due to a mosaic de novo tetrasomy 9p detected by Chromosomal Microarray Analysis. Conventional cytogenetics analysis of the proband was 47,XY,+mar", "subclaim_evaluations": [ { "subclaim": "The case involved a postnatal newborn.", "support_label": "supported", "is_refined": false }, { "subclaim": "The newborn died in early infancy.", "support_label": "supported", "is_refined": false }, { "subclaim": "The newborn had multiple congenital malformations.", "support_label": "supported", "is_refined": false }, { "subclaim": "A mosaic de novo tetrasomy 9p was detected.", "support_label": "supported", "is_refined": false }, { "subclaim": "Chromosomal Microarray Analysis was used.", "support_label": "supported", "is_refined": false }, { "subclaim": "Conventional cytogenetics analysis of the proband was 47,XY,+mar.", "support_label": "supported", "is_refined": false } ] }, { "id": "multiclinsum_test_1665_en.txt", "fulltext": "A 15-year-old averagely built male, having no significant medical history, presented to the casualty with a history of closed trauma of the right knee following self-fall while playing. The mechanism of injury was hyperextension of the knee joint with a valgus stress. On physical examination, the patient had difficulty to move and was unable to stand on his right lower limb. There was visible swelling over his right knee and distal third of thigh with no skin defect. The attitude of the affected limb was that of abduction and external rotation with visible deformity around the right knee. There was a limb shortening of about 3 cm of the right lower limb as compared to the normal limb. The pulsations of the popliteal, tibialis posterior, and dorsalis pedis arteries were positionally palpable.\nAn urgent color Doppler of the right lower limb was done which revealed positional variability in the pulsatality of the popliteal artery with compromised lumen and showing triphasic waveform in certain positions only. The anterior and posterior tibial arteries and dorsalis pedis artery also showed positional variability in the pulsatality with biphasic waveform in certain positions. Thus, the limb was maintained in the position where pulsations of the major arteries were felt . The capillary refill and toe movements were present. No motor or sensory defect was found. Plain AP and lateral X-ray of the right knee revealed a distal femur physeal fracture (Salter and Harris type I) with complete metaphyseal fragment displacement .\nThe patient was operated within 12 h after the injury. Under spinal anesthesia, patient was positioned supine. Closed reduction was attempted using a proximal tibial Steinman pin for skeletal traction and manipulation of the right lower limb. After a gentle continuous traction, manipulation was done in the form of downward pressure on the distal epiphysis and an upward pressure on the proximal metaphyseal fragment of the femur. The reduction was not achieved and hence the fracture site was opened up using a Lateral approach. After the fracture site was visualized, the proximal fragment was held using bone holding forceps and the distal fragment fixed using a clamp , and traction and manipulation was done to achieve anatomic reduction of the fracture site. Reduction was confirmed under fluoroscopy and fixed using three 2.5 mm K-wires in a crossing manner , 2 from lateral to medial side and 1 from medial to lateral side. For additional stability, a long leg splint was given anteriorly in 20–30 degrees flexion of the knee.\nPost-operative radiographs revealed anatomic reduction of the physis of the distal femur with restoration of the normal axis of femur . Post-operative surgical outcome was satisfactory. Close monitoring of the patient was done for the first 24 h postoperatively and no signs of secondary vascular thrombosis were found. Patient was started with hamstring and quadriceps strengthening exercises postoperatively. The slab was kept for 6 weeks, following which the K wires were removed. A review X-ray done showed healing of the fracture , and partial weight bearing was initiated with the help of walker. On subsequent follow-up, after 4 and 8 months, correct limb axis alignment and no significant post-operative complications were found. After 6 months, the patient had become free of pain and had a complete range of movement in the right knee joint . There was no significant angular deformity or shortening in the right lower extremity.", "summary": "Here is a case of right sided distal femur physeal fracture dislocation in a 15-year-old boy having positional vascular compromise (popliteal vessel involvement) as a result of the fracture displacement. He was immediately planned for open reduction and fixation using multiple K wires due to limb threatening condition. We focus on the potential immediate and remote complications, the treatment modality and the functional outcome of the fracture.", "subclaim_evaluations": [ { "subclaim": "The patient is a 15-year-old boy.", "support_label": "supported", "is_refined": false }, { "subclaim": "He has a right-sided distal femur physeal fracture dislocation.", "support_label": "supported", "is_refined": false }, { "subclaim": "The fracture resulted in positional vascular compromise.", "support_label": "supported", "is_refined": false }, { "subclaim": "The popliteal vessel was involved.", "support_label": "supported", "is_refined": false }, { "subclaim": "The fracture displacement caused the vascular compromise.", "support_label": "supported", "is_refined": false }, { "subclaim": "The patient was immediately planned for open reduction.", "support_label": "supported", "is_refined": false }, { "subclaim": "The treatment included fixation using multiple K wires.", "support_label": "supported", "is_refined": false }, { "subclaim": "The decision was made due to a limb-threatening condition.", "support_label": "supported", "is_refined": false }, { "subclaim": "The focus is on potential immediate complications.", "support_label": "supported", "original_label": "not_supported", "reasoning_audit": "No explicit tags provided.", "is_refined": true }, { "subclaim": "The focus is on potential remote complications.", "support_label": "not_supported", "original_label": "not_supported", "reasoning_audit": "No explicit tags provided.", "is_refined": true }, { "subclaim": "The focus is on the treatment modality.", "support_label": "supported", "is_refined": false }, { "subclaim": "The focus is on the functional outcome of the fracture.", "support_label": "supported", "is_refined": false } ] }, { "id": "multiclinsum_test_2732_en.txt", "fulltext": "An 85 year old left hand dominant female presented with a six week history of rapidly growing lump on the thenar eminence. Clinical examination revealed a non-tender large lobulated mobile swelling measuring 5 × 4 cm and involving the whole thenar eminence. A sarcoma was initially suspected. Plain X-ray revealed severe osteopenia with erosive changes in the first Carpometacarpal joint, and a soft tissue swelling around an osteophyte detached from the base of the first metacarpal. MRI reported a septate thin walled cystic structure extending from the first carpo-metacarpal joint space against a background of diffuse active synovitis . In operating theater, a multilobulated lesion with a neck extending to the first CMC joint was observed. The histological analysis revealed a 3.4 g previously opened specimen consistent with a ganglion cyst. The patient made an excellent post-operative recovery with no evidence of recurrence.", "summary": "An 85 year old left hand dominant female presented with a six week history of rapidly growing lump on the thenar eminence. Clinical examination revealed a non-tender large lobulated mobile swelling measuring 5 x 4 cm and involving the whole thenar eminence.", "subclaim_evaluations": [ { "subclaim": "The patient is an 85 year old female.", "support_label": "supported", "is_refined": false }, { "subclaim": "The patient is left hand dominant.", "support_label": "supported", "is_refined": false }, { "subclaim": "The patient had a six week history of a rapidly growing lump.", "support_label": "supported", "is_refined": false }, { "subclaim": "The lump was on the thenar eminence.", "support_label": "supported", "is_refined": false }, { "subclaim": "Clinical examination revealed a non-tender swelling.", "support_label": "supported", "is_refined": false }, { "subclaim": "The swelling was large, lobulated, and mobile.", "support_label": "supported", "is_refined": false }, { "subclaim": "The swelling measured 5 x 4 cm.", "support_label": "supported", "is_refined": false }, { "subclaim": "The swelling involved the whole thenar eminence.", "support_label": "supported", "is_refined": false } ] }, { "id": "multiclinsum_test_1399_en.txt", "fulltext": "A 62-year-old female with MFS was presented to the hospital for an emergency after being diagnosed with cerebral thromboembolism due to atrial fibrillation (AF). Apart from the acute endovascular thrombectomy, the patient was treated for congestive heart failure associated with aortic valve regurgitation with tachycardic AF. Echocardiography revealed severe regurgitation with reduced left ventricular ejection function (32%) and massive left ventricular diastolic dimension (88 mm). Aortic valve was tricuspid, and the eccentric regurgitation jet revealed prolapse of right coronary cusp. The aortic root was moderately dilated (42 mm). After 2 months of treatment, the patient was referred to our hospital for the surgical treatment of aortic valve regurgitation. The patient was free from the sequela of brain stroke, but complained of general fatigue consistent with a New York Heart Association class III condition with weakened leg muscle strength due to disuse syndrome. N-terminal pro-brain natriuretic peptide (NT-proBNP) level at admission was 3964 pg/mL. Sinus rhythm had been maintained after initiating oral amiodarone. The diameter of the aortic root in this patient was below the size required for indicating surgical treatment for MFS . In addition, the dimension and systolic function of the left ventricle suggested the progression of ventricular remodeling. Therefore, aortic valve replacement was selected primarily for the prevention of heart failure. In contrast, there were various options for the management of AF in the present case. Left atrial appendage closure was thought to be an appropriate treatment option to prevent recurrence of cerebral thromboembolism because AF had been effectively controlled by antiarrhythmics and the patient would receive coumadin following mechanical valve implantation. Thus, combined surgery involving aortic valve replacement and left atrial appendage (LAA) closure was planned in order to achieve early rehabilitation and return to daily life. Her chest XP revealed severe scoliosis . Spirometry showed normal lung function. A computed tomography was performed to determine the optimal intercostal space to access both the aortic valve and LAA . Three-dimensional reconstruction imaging showed that right lower hemisternotomy in a reverse “L” fashion was the optimal approach for clamping and incising the aorta with the ectopic origin of the right coronary artery arising from anteromedial surface of ascending aorta .\nThe patient was intubated using a double-lumen tube and laterally positioned at approximately 30 degrees right-side up. A skin incision was made from the second intercostal space down to the xiphoid process, after which the chest was opened via right lower hemisternotomy. The surgical field was secured using a Kent retractor (Takasago medical Inc., Tokyo, Japan) and sternal retractor with the costal arch folded back. Cardiopulmonary bypass was established with femoral arterial and cavoatrial cannulation. The ascending aorta was cross-clamped using flexible aortic clamp . Cardiac arrest was obtained using bidirectional cardioplegia. An oblique aortotomy was created 10 mm medial to the ostium of the right coronary artery. The aortic valve cusp was then resected, and a 25-mm mechanical valve was implanted in the intra-annular position. After closing the aortotomy, the 40-mm AtriClip (Atricure Inc, Westchester, OH, USA) was applied to the stump of the LAA before releasing the aortic cross-clamp. The patient was carefully weaned from cardiopulmonary bypass, which required an intraaortic balloon pump for the treatment of perioperative low-output syndrome due to reduced left ventricular function. The extracorporeal circulation time and aortic cross-clamp time were 165 and 87 min, respectively. The total operative time was 303 min. Transfusion of 4 units of red blood cells and 6 units of fresh frozen plasma was required during the surgery.\nThe patient was extubated on postoperative day 2, and the intraaortic balloon pump was removed 2 days after the extubation. Further, she was then transferred to the rehabilitation center for the management of her disuse syndrome on postoperative day 21; thereafter, she has been living independently without any cardiac and cerebrovascular event.", "summary": "A 62-year-old female with MFS was referred to our hospital after being diagnosed with severe aortic regurgitation and paroxysmal atrial fibrillation with a history of cerebral thromboembolism. The aortic valve showed severe insufficiency due to cusp prolapse, whereas the aortic root was moderately dilated (42 mm). Echocardiography revealed severe regurgitation with reduced left ventricular ejection function (32%) and massive left ventricular diastolic dimension (88 mm). Moreover, combined aortic valve replacement and left atrial appendage closure was indicated. However, the patient had chest deformity due to severe scoliosis. Thus, conventional full sternotomy or thoracotomy was considered an inappropriate surgical approach. Lower hemisternotomy was selected on the basis of three-dimensional reconstruction imaging of the aorta, left atrial appendage, sternum, and rib. Sternal elevation and rib retraction with the costal arch folded back provided enough surgical field for the combined procedures to be safely conducted. The postoperative course was uneventful, except for predicted prolonged mechanical ventilation with the assistance of intraaortic balloon pumping. Thereafter, the patient has been free from any cardiac and cerebrovascular event.", "subclaim_evaluations": [ { "subclaim": "The patient is a 62-year-old female.", "support_label": "supported", "is_refined": false }, { "subclaim": "The patient has Marfan syndrome.", "support_label": "supported", "is_refined": false }, { "subclaim": "The patient was diagnosed with severe aortic regurgitation.", "support_label": "supported", "is_refined": false }, { "subclaim": "The patient has a history of cerebral thromboembolism.", "support_label": "supported", "is_refined": false }, { "subclaim": "Echocardiography showed aortic cusp prolapse.", "support_label": "supported", "is_refined": false }, { "subclaim": "The aortic root was 42 mm in diameter.", "support_label": "supported", "is_refined": false }, { "subclaim": "Echocardiography showed a left ventricular ejection fraction of 32%.", "support_label": "supported", "is_refined": false }, { "subclaim": "The left ventricular diastolic dimension was 88 mm.", "support_label": "supported", "is_refined": false }, { "subclaim": "Combined aortic valve replacement and left atrial appendage closure was indicated.", "support_label": "supported", "is_refined": false }, { "subclaim": "The patient had chest deformity due to severe scoliosis.", "support_label": "supported", "is_refined": false }, { "subclaim": "Conventional full sternotomy was considered an inappropriate surgical approach.", "support_label": "supported", "is_refined": false }, { "subclaim": "Lower hemisternotomy was selected.", "support_label": "supported", "is_refined": false }, { "subclaim": "Three-dimensional reconstruction imaging was used to plan the surgery.", "support_label": "supported", "is_refined": false }, { "subclaim": "Sternal elevation and rib retraction provided enough surgical field.", "support_label": "supported", "is_refined": false }, { "subclaim": "The combined procedures were safely conducted.", "support_label": "supported", "is_refined": false }, { "subclaim": "The postoperative course was uneventful.", "support_label": "supported", "is_refined": false }, { "subclaim": "Prolonged mechanical ventilation was predicted.", "support_label": "not_supported", "original_label": "not_supported", "reasoning_audit": "No explicit tags provided.", "is_refined": true }, { "subclaim": "Intraaortic balloon pumping was used.", "support_label": "supported", "is_refined": false }, { "subclaim": "The patient has been free from any cardiac event.", "support_label": "supported", "is_refined": false }, { "subclaim": "The patient has been free from any cerebrovascular event.", "support_label": "supported", "is_refined": false } ] }, { "id": "multiclinsum_test_3302_en.txt", "fulltext": "The patient is a five-year-old female with a past medical history of Wolff–Parkinson– White syndrome, asthma, and oppositional defiant disorder who presented to the emergency department with unwitnessed ingestion of a foreign body. The patient’s mother endorsed that on 29 November 2020 at 21:00, the patient complained of chest pain and admitted to previously swallowing a silver object. Upon arrival at the hospital, she had four episodes of non-bloody, nonbilious emesis, and epigastric pain. A chest X-ray showed a round metallic object projecting over the mid esophagus, with a double halo and step-off appearance, consistent with button battery (BB) ingestion. Due to the potential for rapid onset of damage following BB ingestion, the patient was subsequently admitted for emergent endoscopic removal of the BB, and directions were given that she was to receive nothing by mouth (NPO).\n\nWe performed an esophogastroduodenoscopy (EGD) 6 h after ingestion and discovered a 20 mm BB in the middle third of the esophagus. We successfully removed the BB with rat tooth forceps without complications. Visualization of the site showed mucosal ulceration and erosion. According to the commonly used Zargar classification of esophageal injuries, this lesion was determined to be Grade 2B due to the erosion’s circumferential nature. The endoscope was advanced to the stomach and showed no damage. A nasogastric (NG) tube was not placed at the time of the endoscopy.\n\nThe following day, the patient endorsed substernal chest pain and dysphagia with saliva. Her diet remained NPO, and she was started on ceftriaxone and intravenous (IV) pantoprazole. A follow-up chest X-ray on day two showed no evidence of cardiopulmonary disease, pneumomediastinum, or pneumothorax. An esophagram on day three showed mild irregularity in the mid-esophagus but no contrast extravasation to suggest perforation.\n\nWe performed a repeat EGD on day four to assess esophageal mucosa healing and place an NG tube for feeds. The endoscope was progressed to the middle third of the esophagus, revealing a single, non-bleeding, posterior erosion with sloughing of necrotic tissue. A 10 French NG tube was placed under direct visualization. Post endoscopy, we initiated feeds via NG tube, but the patient developed a fever of 38.8 °C. We then added IV cefepime and metronidazole to her medication regimen and held feeds due to the concern for mediastinitis. An MRI showed possible inflammation in the posterior mediastinum. However, the patient’s fever subsided, and a chest X-ray did not reveal signs of esophageal perforation. On day six, we restarted feeds via NG tube and discontinued antibiotics. On day eight, a repeat esophagram showed persistent irregularity of the posterior esophageal wall consistent with ulceration. She was discharged the same day on NG tube feeds, omeprazole, and instructed to avoid food and water by mouth.\n\nThe patient returned to the ED the following day with bilious vomiting following bolus tube feeds. An X-ray revealed that the tip of the NG tube had been displaced to the duodenum, which was then pulled back to the stomach without complication.\n\nAt clinic follow-up 4 weeks following ingestion, the patient was tolerating feeds via NG tube and sips of water. The following day, we used a GIF-HQ 190 endoscope of 9.9 mm diameter that showed moderate stenosis with friable mucosa in the middle third of the esophagus. We could not traverse the stenosis with the endoscope. Due to the lack of equipment available and the endoscopist’s minimal experience with strictures, we did not attempt dilation at that time. We performed an esophagram two days later to assess the length of the stricture, but there was no evidence of strictures, perforation, or fistulas on imaging in neither the lateral view or the AP view.\n\nAbout seven weeks post ingestion, she returned for an EGD with possible stricture dilation and NG tube removal. The patient was tolerating a full liquid diet by mouth in addition to NG tube feeds, with no symptoms of fever, chest pain, or dysphagia. Upon introduction, the endoscope could not pass through a severe esophageal stenosis 15 cm from the incisors. Balloon dilation was performed to 10 mm, 12 mm, 13.5 mm, and twice to 15 mm, after which we passed the endoscope to the stomach and removed the NG tube. The patient tolerated the procedure well and was discharged to home once she tolerated liquids by mouth.", "summary": "We present the case of a five-year-old female who presented with vomiting following unwitnessed button battery ingestion. The battery was impacted in the middle esophagus for at least six hours. Endoscopy was performed for immediate removal and showed a Grade 2B erosion, warranting nasogastric tube placement. The patient remained asymptomatic following discharge and had a barium swallow that was read as normal. However, a repeat endoscopy one month later visualized stricture formation at the previous battery injury site.", "subclaim_evaluations": [ { "subclaim": "The patient is a five-year-old female.", "support_label": "supported", "is_refined": false }, { "subclaim": "The patient had vomiting following unwitnessed button battery ingestion.", "support_label": "supported", "is_refined": false }, { "subclaim": "The battery was impacted in the middle esophagus.", "support_label": "supported", "is_refined": false }, { "subclaim": "The battery was impacted for at least six hours.", "support_label": "supported", "is_refined": false }, { "subclaim": "Endoscopy was performed for immediate removal.", "support_label": "supported", "is_refined": false }, { "subclaim": "Endoscopy showed a Grade 2B erosion.", "support_label": "supported", "is_refined": false }, { "subclaim": "Nasogastric tube placement was performed.", "support_label": "supported", "is_refined": false }, { "subclaim": "The patient was asymptomatic following discharge.", "support_label": "not_supported", "original_label": "not_supported", "reasoning_audit": "No explicit tags provided.", "is_refined": true }, { "subclaim": "A barium swallow was read as normal.", "support_label": "not_supported", "original_label": "not_supported", "reasoning_audit": "No explicit tags provided.", "is_refined": true }, { "subclaim": "A repeat endoscopy was performed one month later.", "support_label": "supported", "is_refined": false }, { "subclaim": "Stricture formation was visualized at the previous battery injury site.", "support_label": "supported", "is_refined": false } ] }, { "id": "multiclinsum_test_3363_en.txt", "fulltext": "A 52-year-old Hispanic woman from Kern county, southern California, with a past medical history of gastroesophageal reflux disease, osteopenia, complex regional pain syndrome of the right upper extremity status post-carpal tunnel release surgery, lumbar spondylosis at L5-S1, and iron deficiency anemia, presented to her primary care physician for the evaluation of tender erythematous nodules on her thighs that had been present for approximately 1 month. Based on the clinical appearance and the geographical region of presentation, the patient was suspected of having erythema nodosum secondary to valley fever (coccidioidomycosis). The patient was prescribed fluconazole 200 mg daily, pending results from serological testing for coccidioidal immunoglobin M (IgM) and immunoglobin G (IgG). However, there was no improvement when the patient returned for a follow-up visit after 30 days of treatment. Additionally, the coccidioidal IgM and IgG tests were negative. Thus, treatment with fluconazole was discontinued and the patient was referred to a pulmonologist, who ordered tests to rule out sarcoidosis, tuberculosis, and thrombosis.\n\nThe following results were obtained: angiotensin 1-converting enzyme levels (<5 U/L) (reference range: 9–67 U/L); QuantiFERON tuberculosis gold (interferon-gamma release assay [negative]); activated partial thromboplastin time (27 s); prothrombin time (9.6 s); international normalized ratio (0.9); and von Willebrand factor antigen (121 IU/dL). Based on these results, sarcoidosis, tuberculosis, and thrombosis were ruled out and no definitive diagnosis was made. The patient was then referred to a dermatologist, who suspected a diagnosis of LET based on clinical presentation. A punch biopsy of the skin lesion measuring 0.4 × 0.4 × 0.5 cm was taken from the right lateral thigh.\n\nThe histopathology report on the punch biopsy was as follows: “superficial and deep perivascular and interstitial mononuclear inflammatory cell infiltrate with increased dermal mucin deposition. Periodic acid-Schiff staining was negative for fungal organisms; colloidal iron (mucin stain) showed increased dermal mucin deposition. There was no evidence of vasculitis or malignancy.” The histopathologist commented that these findings would be compatible with connective tissue disease/LET or an interstitial variant of granuloma annulare in an appropriate clinical setting. To arrive at a definitive diagnosis, the histopathologist advised to correlate clinical findings with serologic studies and to perform a direct immunofluorescence study to rule out morphea versus LET. Direct immunofluorescence study of a biopsy of the lesion, measuring 0.3 × 0.3 × 0.6 cm which was taken from the right lateral thigh, showed no specific immune deposits. Due to the high index of suspicion of LET, and its association with other autoimmune conditions, especially systemic lupus erythematosus, the patient was subsequently referred to a rheumatologist.\n\nThe rheumatologist’s physical examination demonstrated a left thigh nodule, and the right thigh exhibited warmth, erythema, and tenderness to palpation. A full screening for autoimmune diseases was done, which included the following diagnostic studies: complete blood count, comprehensive metabolic panel, c-antineutrophilic cytoplasmic antibody, p-antineutrophilic cytoplasmic antibody, anti-nuclear antibody, proteinase-3 antibody, beta-2-glycoprotein IgG/IgM/IgA, cardiolipin IgG/IgM/IgA, anti-Ro antibodies and anti-La antibodies, anti-Smith antibody, ribonucleoprotein antibody, erythrocyte sedimentation rate, C-reactive protein, complement C3 and complement C4, dilute Russell’s viper venom time, thyroid peroxidase antibody, double-stranded deoxyribonucleic acid antibody enzyme immunoassay, cyclic citrulline peptide antibody IgG, rheumatoid factor, and thyroid-stimulating hormone. Remarkably, all diagnostic studies were within normal limits, except the erythrocyte sedimentation rate, which was elevated at 39 (reference range: <25 mm/h). Thus, based on clinical, laboratory, and histopathological findings, LET was diagnosed, and other autoimmune conditions were ruled out. The patient was treated with hydroxychloroquine 200 mg daily and she showed significant improvement within 2 weeks of the follow-up visit.", "summary": "A 52-year-old Hispanic female presented with tender erythematous nodules on her thighs for approximately 1 month. She was suspected of having erythema nodosum secondary to coccidioidomycosis and was prescribed fluconazole 200 mg for 30 days but showed no improvement. However, histopathological and direct immunofluorescence tests later confirmed a diagnosis of LET. The patient was treated with hydroxychloroquine, and the lesions improved remarkably after 2 weeks.", "subclaim_evaluations": [ { "subclaim": "The patient is a 52-year-old Hispanic female.", "support_label": "supported", "is_refined": false }, { "subclaim": "She had tender erythematous nodules on her thighs.", "support_label": "supported", "is_refined": false }, { "subclaim": "The nodules had been present for approximately 1 month.", "support_label": "supported", "is_refined": false }, { "subclaim": "She was suspected of having erythema nodosum.", "support_label": "supported", "is_refined": false }, { "subclaim": "The suspected cause was coccidioidomycosis.", "support_label": "supported", "is_refined": false }, { "subclaim": "She was prescribed fluconazole 200 mg for 30 days.", "support_label": "supported", "is_refined": false }, { "subclaim": "She showed no improvement with fluconazole.", "support_label": "supported", "is_refined": false }, { "subclaim": "Histopathological tests confirmed a diagnosis of LET.", "support_label": "supported", "is_refined": false }, { "subclaim": "Direct immunofluorescence tests confirmed a diagnosis of LET.", "support_label": "not_supported", "original_label": "not_supported", "reasoning_audit": "No explicit tags provided.", "is_refined": true }, { "subclaim": "The patient was treated with hydroxychloroquine.", "support_label": "supported", "is_refined": false }, { "subclaim": "The lesions improved remarkably after 2 weeks.", "support_label": "supported", "is_refined": false } ] }, { "id": "multiclinsum_test_1366_en.txt", "fulltext": "A 63-year-old woman presented with a firm 7 cm multilobular tender mass located in the region of the right sternocleidomastoid directly above the clavicle. She had multiple comorbidities including renal failure, systemic lupus erythematosus, and protein S deficiency, a history of transient ischemic attack, deep vein thrombosis, and pulmonary embolism, and longstanding malnourishment requiring jejunostomy tube placement. The firm mass was identified 1 month after an unsuccessful attempt at placing a right internal jugular vein central line. When the central line was originally placed, she developed pain and swelling of her neck. The swelling was pulsatile at that time and enlarging. She was offered surgery as the standard of care for her condition which she refused because she did not want to undergo an invasive procedure and was aware of the risks involved with holding her anticoagulant medication. She had two thrombin injections in the mass since without success. She complained of right neck pain. She was not having any difficulty breathing and denied shortness of breath.\nSoft tissue ultrasound after the two thrombin injections showed pseudoaneurysm and a 7 × 3.3 × 4 cm multilobular hematoma at the base of the right neck. CTA of the neck showed a corresponding heterogeneous mass. The pseudoaneurysm was seen measuring 1.5 cm at the internal margin of the hematoma. Serial imaging with CTA demonstrated enlargement over a 2-week interval .\nAngiogram showed blush of contrast coming off of the sternocleidomastoid branch of the superior thyroid artery identifying the location of the pseudoaneurysm . This branch was embolized using glue. Repeat angiogram showed successful embolization and no contrast blush.\nOn follow-up one month later, the mass was no longer pulsatile but still present on physical exam. CTA of the neck showed a decrease in size from the previous CTA .\nOn follow-up 8 months later, she was found to have a soft neck with no mass on physical exam.", "summary": "A 63-year-old female with multiple comorbidities presented with a firm 7 cm tender mass located in the right neck. Ultrasound showed pseudoaneurysm and a 7 × 3.3 × 4 cm multilobular hematoma in the location of the previous central line. CTA showed a corresponding heterogeneous mass. Serial imaging demonstrated enlargement over 2 weeks. Angiogram showed contrast blush off of the SBSTA.", "subclaim_evaluations": [ { "subclaim": "The patient is a 63-year-old female.", "support_label": "supported", "is_refined": false }, { "subclaim": "The patient has multiple comorbidities.", "support_label": "supported", "is_refined": false }, { "subclaim": "The patient had a firm 7 cm tender mass in the right neck.", "support_label": "supported", "is_refined": false }, { "subclaim": "Ultrasound showed a pseudoaneurysm.", "support_label": "supported", "is_refined": false }, { "subclaim": "Ultrasound showed a 7 × 3.3 × 4 cm multilobular hematoma.", "support_label": "supported", "is_refined": false }, { "subclaim": "The hematoma was in the location of the previous central line.", "support_label": "supported", "is_refined": false }, { "subclaim": "CTA showed a corresponding heterogeneous mass.", "support_label": "supported", "is_refined": false }, { "subclaim": "Serial imaging demonstrated enlargement over 2 weeks.", "support_label": "supported", "is_refined": false }, { "subclaim": "Angiogram showed contrast blush off of the SBSTA.", "support_label": "supported", "is_refined": false } ] }, { "id": "multiclinsum_test_707_en.txt", "fulltext": "A 30-year-old male with a known history of KTS presented with a rapidly enlarging subcutaneous central frontal mass, measuring 41 × 47 × 54 mm since its formation just 3 months earlier causing pain and an obvious cosmetic defect. The patient had no demonstrable neurological signs on examination with normal pre-operative laboratory studies, however, had previous episodes of significant hemorrhage arising from the lesion as a result of minor trauma.\nClinically, the patient was dysmorphic, most notably severe soft tissue overgrowth, bilateral lower limb lymphoedema, and cellulitis. Despite this, he had no history of other complications arising as a result of his KTS such as malignancy or peripheral hemangioma.\nRadiological findings initially began with computed tomography angiogram, which revealed a destructive expansile arterially-enhancing lesion arising from the frontal bone. Heterogenous contrast enhancement on magnetic resonance imaging further defined the lesional dural involvement and invasion into the superior sagittal sinus sparring cerebral parenchyma.\nGross total resection consisted of a T-shaped incision followed by bilateral frontal craniectomies . The vascular lesion was identified arising from frontal bone and within the superior saggital sinus. The lesion was resected en bloc from calvaria. A custom-made titanium implant was used for cranioplasty .\nPostoperatively, the patient had a full recovery. Histopathological hemotoxylin and eosin stains revealed the lesion extending through bone, with a small foci of extramedullary hemopoiesis, consistent with hemangioma. There has been no evidence of recurrence 6 months post resection.", "summary": "A 30-year-old male presented with a rapidly enlarging frontal skull lesion that had developed in only 3 months. Radiological investigation revealed a highly vascular lesion attached to the frontal bone. The lesion was surgically resected with the patient making complete recovery. Histopathology was consistent with an osseous hemangioma.", "subclaim_evaluations": [ { "subclaim": "The patient is a 30-year-old male.", "support_label": "supported", "is_refined": false }, { "subclaim": "The lesion was located on the frontal skull.", "support_label": "supported", "is_refined": false }, { "subclaim": "The lesion had developed over 3 months.", "support_label": "supported", "is_refined": false }, { "subclaim": "Radiological investigation showed a highly vascular lesion.", "support_label": "supported", "is_refined": false }, { "subclaim": "The lesion was attached to the frontal bone.", "support_label": "supported", "is_refined": false }, { "subclaim": "The lesion was surgically resected.", "support_label": "supported", "is_refined": false }, { "subclaim": "The patient made a complete recovery.", "support_label": "supported", "is_refined": false }, { "subclaim": "Histopathology was consistent with an osseous hemangioma.", "support_label": "supported", "is_refined": false } ] }, { "id": "multiclinsum_test_2089_en.txt", "fulltext": "A 25-year-old woman with liver cirrhosis secondary to autoimmune hepatitis diagnosed at a local hospital presented with fatigue, painless jaundice and lower limb swelling for two weeks, there was no evidence of hypertension or protenuria excluding the possibility of pre-eclampsia or eclampsia. There was no history of ascites, spontaneous bacterial peritonitis or hepatic encephathy. Pregnancy was terminated at 27th week at the local hospital. She was on 40 mg of Prednisolone daily for possible autoimmune hepatitis, soon after, she developed steroid induced diabetes. She was referred to our hospital after 6 weeks of the intial presentation with two episodes of hematemesis, tachycardia (heart rate 120) and blood pressure of 84/50. The patient was admitted to ICU and started on octreotide and Piperacillin/Tazobactam. Gastroscopy revealed gastric varices and bleeding was endoscopically controlled. During admission, liver function tests worsened, and transjugular liver biopsy showed established liver cirrhosis with no obvious active pathology. We started tapering the steroids slowly after being on 40 mg for 4 weeks with no improvement of jaundice without evidence of active inflammation on liver biopsy. During admission, she developed painful, erythematous lesion on her right forearm at the IV access area that became necrotic and spread quickly and increased in size over a period of 24 hours. The lesion included the skin and subcutaneous tissue and was flecked with tiny black spots. Vital signs: temp 37.4ºC, BP 128/80 mmHg, pulse 66 /min, RR 20 /min, SaO2 100% on room air.\nChest was clear to auscultation and cardiovascular exam was normal. Abdomen was soft and lax, distended with ascites but no tenderness. Extremities showed mild lower limb edema. Her investigations showed a white cell count 14.24 x 103/mm3 with Neutrophils of 86%, hemoglobin 9.2 g/dl, and platelets of 103000 /mm3 , LFT: total bilirubin 457 umol/L, direct 321, alkaline phosphatase 430U/L, ALT 174U/L, AST 248U/L, gamma GT 227, total protein 51g/L, albumin 18g/L, PT 19.4 and INR was 1.7, PTT 58, renal function test was within normal, fasting glucose 9.8 mmol/L. ESR was 2, Blood culture showed no growth after 5 days.\nMRI of the right upper extremity showed inflammatory changes through the anterior compartment of the forearm suggestive of fasciitis.\nShe was taken to the operating room for debridement after 24 hours, delay was due to anesthesia issues in this high risk patients. At this point after 18 days of admission, Prednisolone dose reached 20 mg daily and antibiotic changed from Piperacillin/Tazobactam to Imipenem when the culture results from tissue biopsy grew Klebsiella Pneumonia extended spectrum b lactamase producer (ESBL).\nHistopathological examination of the debrided soft tissue revealed necrotic subcutaneous fat and skeletal muscle fibers invaded by broad hyphae, irregularly branched, with rare septations suggestive of mucormycosis ( and ). There were no clinical symptoms or signs of visceral dissemination of infection to warrant further imaging or biopsy. The patient started on Amphotericin B (Abelcet®) 300mg IV OD after 20 days of admission and was continued on imipenem. In spite of surgical debridement, her condition continued to deteriorate and ended up after 6 days with above elbow amputation, tissue-cultures for both bacteria and fungi were negative. Amphotericin B was stopped after amputation as it was considered that the source of infection was eliminated but was restarted again 3 days after discontinuation with imipenem continued all through with the addition of vancomycin. The patient continued to deteriorate and the stump showed signs of disseminated infection, which proved to be invasive mucormycosis infection. Right shoulder disarticulation done but she passed away 2 days later due to multi-organ failure after 35 days in the hospital.", "summary": "We described a rare case of forearm infection originating in a traumatic intravenous access portal in a 25 year-old woman with liver cirrhosis secondary to autoimmune hepatitis.", "subclaim_evaluations": [ { "subclaim": "The patient was a 25 year-old woman.", "support_label": "supported", "is_refined": false }, { "subclaim": "The patient had liver cirrhosis.", "support_label": "supported", "is_refined": false }, { "subclaim": "The liver cirrhosis was secondary to autoimmune hepatitis.", "support_label": "supported", "is_refined": false }, { "subclaim": "The infection originated in a traumatic intravenous access portal.", "support_label": "supported", "is_refined": false }, { "subclaim": "The infection was in the forearm.", "support_label": "supported", "is_refined": false }, { "subclaim": "The case was described as rare.", "support_label": "supported", "is_refined": false } ] }, { "id": "multiclinsum_test_1133_en.txt", "fulltext": "A 27-year-old male involved in a motor vehicle accident was brought to Emergency Department room with respiratory distress. He was intubated upon arrival due to low Glasgow Coma Scale (GCS) with extensive maxillofacial injuries. Thoracic examination showed reduced air entry at right chest wall region with palpable crepitus on his right neck region due to subcutaneous emphysema from the neck to the anterior chest wall. The heart sound was barely audible. A curvilinear transducer on the right second intercostal ribs shows the absence of sliding signs, suggestive of right pneumothorax. A FAST scan was performed, but, on subxiphoid view of the heart, only the right ventricle is seen during diastole. Part of the cardiac image was obscured by A-lines . This raised a suspicion of pneumopericardium given the subxiphoid window was showing partly A-lines and the other half of anatomy partially obscured. We proceeded with focused cardiac ultrasound, and only A-lines were visible on parasternal long axis (PLAX), parasternal short axis (PSAX), and apical four chamber (A4C) views.\nThe patient underwent head and chest CT scan that confirmed the diagnosis of Le Fort II facial bone injury, right pneumothorax, and right pulmonary contusion with pneumopericardium . The pneumopericardium was treated conservatively, but other injuries were treated accordingly.", "summary": "A young man involved in a car accident and sustained blunt thoracic injuries, among others. As part of primary survey, FAST scan was performed. Subxiphoid view to look for evidence of pericardial effusion showed part of the cardiac image obscured by A-lines. Other cardiac windows showed only A-lines, as well. A suspicion of pneumopericardium was raised and CT scan confirmed the diagnosis.", "subclaim_evaluations": [ { "subclaim": "The patient is a young man.", "support_label": "supported", "is_refined": false }, { "subclaim": "The patient was involved in a car accident.", "support_label": "supported", "is_refined": false }, { "subclaim": "The patient sustained blunt thoracic injuries.", "support_label": "supported", "is_refined": false }, { "subclaim": "A FAST scan was performed as part of the primary survey.", "support_label": "supported", "is_refined": false }, { "subclaim": "A subxiphoid view was obtained to look for pericardial effusion.", "support_label": "supported", "is_refined": false }, { "subclaim": "The subxiphoid view showed part of the cardiac image obscured by A-lines.", "support_label": "supported", "is_refined": false }, { "subclaim": "Other cardiac windows showed only A-lines.", "support_label": "supported", "is_refined": false }, { "subclaim": "A suspicion of pneumopericardium was raised.", "support_label": "supported", "is_refined": false }, { "subclaim": "A CT scan confirmed the diagnosis of pneumopericardium.", "support_label": "supported", "is_refined": false } ] } ]