Neural language models (LMs) can be used to evaluate the truth of factual statements in two ways: they can be either queried for statement probabilities, or probed for internal representations of truthfulness. Past work has found that these two procedures sometimes disagree, and that probes tend to be more accurate than LM outputs. This has led some researchers to conclude that LMs "lie" or otherwise encode non-cooperative communicative intents. Is this an accurate description of today's LMs, or can query--probe disagreement arise in other ways? We identify three different classes of disagreement, which we term confabulation, deception, and heterogeneity. In many cases, the superiority of probes is simply attributable to better calibration on uncertain answers rather than a greater fraction of correct, high-confidence answers. In some cases, queries and probes perform better on different subsets of inputs, and accuracy can further be improved by ensembling the two.

Cognitive Dissonance: Why Do Language Model Outputs Disagree with Internal Representations of Truthfulness?

Kikuchi-Fujimoto disease is a form of benign necrotizing lymphadenitis also known as histiocytic necrotizing lymphadenitis. While Kikuchi disease is a globally prevalent disease, it is predominantly seen in the Asian population. Etiology can be traced back to dysregulated immune responses triggered by viral or autoimmune factors. Here we present a case report to emphasize the importance of considering Kikuchi disease and possible etiologies, highlighting the need for increased awareness and recognition of this rare condition. A 28-year-old female with a history of hypothyroidism, IBS, and GERD complained of sore throat, intermittent epigastric pain, mild heartburn, and fever and was taking PPIs without any improvement. Abdominal USG was negative for any pathology. She presented with bilateral enlarged cervical lymph nodes and worsening of symptoms 1.5 months later. Ciprofloxacin was prescribed which failed to improve the symptoms. CT scan of the neck showed an enlarged thyroid gland with diffuse lymphadenopathy. Labs showed elevated TSH, for which the levothyroxine dose was increased, despite that she still continued to have symptoms. LDH and CRP were normal. Rheumatology, oncology, and infectious disease specialists were called upon for further evaluation. Excisional Lymph node biopsy showed areas of extensive necrosis with karyorrhectic debris, surrounded by histiocytes and small lymphocytes, suggestive of necrotizing lymphadenitis, specifically consistent with Kikuchi disease. Immunophenotyping by flow cytometry demonstrated normal CD4+ and CD8+ T cell populations without any evidence of clonal lymphoid expansion. AFB and GMS stains were negative for infection. Hydroxychloroquine 200 mg twice daily was given, which resulted in the resolution of her symptoms. Kikuchi disease’s origins can be traced back to Japan, where it was initially documented. More prevalent in the young female Asian population under the age of 30. It presents as tender, enlarged nodes, primarily in the cervical region along with lymphadenopathy, fever, erythematous rash, joint pain, fatigue, arthritis, and hepatosplenomegaly. It becomes important to consider Kikuchi disease in patients presenting with symptoms that can be attributed to sore throat related to GERD, followed by the development of fever with cervical lymph node enlargement.

Unusual presentation of sore throat with bilateral lymphadenopathy in a hypothyroid patient: Kikuchi Fujimoto Disease, A case report.

Background: Endoscopy is commonly used to diagnose upper gastrointestinal (GI) system disorders. However, excess mucus can significantly impair visualization, and reducing mucus intra-procedurally can increase procedure time. Several studies have evaluated the efficacy of pre-medication with mucolytic agents prior to gastroscopy to improve the diagnostic yield of endoscopy and reduce procedural time. Here, we systematically review recent evidence assessing the efficacy of mucolytic agents, including N-acetyl cysteine (NAC), in improving visibility in upper GI endoscopy.
Methods: Studies were identified by interrogating the PubMed database using the search terms "endoscopy" and "N-acetyl cysteine" for the period of 2016-2023. Only randomized control trials were included in the search. Records written in languages other than English were excluded. Ten (10) records matching these criteria were retrieved. Title and abstract screening resulted in five (5) records, which were subsequently extracted.
Results: The studies were conducted in the United Kingdom, Chile, Portugal, Thailand, and the Czech Republic. Four (4) studies consisted of randomized, double-blinded, placebo-controlled trials, while the remaining study was a randomized, non-blinded controlled trial. Four (4) of the studies showed that pre-administration of NAC (600 mg) plus simethicone (100 mg) significantly improved the visibility of the upper GI tract (esophagus, stomach, and duodenum) when compared to placebo control. The only study that failed to show an improvement in visibility scores was attributed to sub-threshold doses of NAC (400 mg) and simethicone (20 mg). Although none of the studies included an arm consisting of NAC alone, one study comparing simethicone +/- NAC showed superior visibility when NAC was administered at a high dose (1000 mg), while another study comparing simethicone +/- NAC failed to show improvement when NAC was administered at a moderate dose (600 mg). Lastly, one study found that the procedure time and volume of mucosal cleansing solution required were significantly reduced when NAC and simethicone were administered together.


Conclusion: Our survey of recent randomized control trials supports that pre-medication with NAC (600-1000 mg) and simethicone (100 mg) significantly improves the visibility of the upper GI mucosal surfaces during upper endoscopic procedures and, therefore, may improve diagnostic yield in settings where visibility is impaired. This approach may be particularly useful in lower-resource settings where less sophisticated endoscopic tools are utilized.

Efficacy of N-Acetyl Cysteine in the Prevention of Post-Operative Atrial Fibrillation and Acute Kidney Injury Post-Cardiac Surgery: A Systematic Review

Background
Coronaviruses, including SARS-CoV-2, cause the respiratory disease known as COVID-19. Some individuals experience persistent symptoms, referred to as long COVID. Among the complications reported after COVID-19 are Guillain-Barre Syndrome (GBS) and its variant, Miller Fisher Syndrome (MFS). MFS causes muscle weakness, ataxia, and ophthalmoplegia. Treatment typically includes intravenous immunoglobulin (IVIG) or plasmapheresis. While most COVID-19-associated MFS cases improve with IVIG, this case highlights a patient who did not show symptomatic relief.
Case Presentation
A 57-year-old male with a medical history of prior COVID-19 infection, facial fracture repair, and treated syphilis presented to the emergency department (ED) with sudden-onset double vision, pain behind the left eye, dizziness, frontal headache, and generalized weakness. The diplopia began five days after the initial COVID-19 diagnosis and progressively worsened. The patient had experienced a dry cough and rhinorrhea prior to admission, with a confirmed SARS-CoV-2 infection. On admission, the patient exhibited facial nerve weakness, impaired eye movement, ptosis, diminished reflexes, and generalized weakness. Sensation, cerebellar function, and gag reflex were normal, but the patient required a cane for ambulation. The patient 
underwent a comprehensive evaluation and was diagnosed with Miller Fisher Syndrome. Treatment with IVIG and prednisone was administered, but there was no improvement in symptoms even after 8 weeks.
Discussion
This case report presents a unique case of a patient who developed MFS following a COVID-19 infection. Despite receiving IVIG treatment, the patient did not experience any improvement in symptoms even after 8 weeks. This is a notable finding as most reported cases of COVID-19-associated MFS have shown some improvement after IVIG therapy within 2 weeks. The patient's prolonged lack of symptomatic improvement raises questions about potential modifications of MFS or resistance to standard treatment. Further research is needed to understand the relationship between COVID-19 and MFS, including potential predisposing factors and pathophysiological mechanisms. The case highlights the need for targeted therapies and diagnostic markers for MFS in the context of COVID-19, as well as the importance of early detection and understanding the impact of different strains of the virus on neurological manifestations.



Title of Persistent Miller Fisher Syndrome Following COVID-19 Infection: A Case Report

We herein report a case of a 24-year-old female who presented to her primary care physician with the chief complaint of increased forgetfulness and brain fog. Further history revealed that she had also been having shortness of breath, nausea/vomiting, fatigue, myalgias, and a 20 lb weight loss. A chest x-ray was ordered and was read as cardiomegaly with severe pulmonary edema. The patient was notified by her PCP to immediately present to an Emergency Department. Upon initial presentation to the hospital, the patient was normotensive, mildly tachycardic at 104 bpm, with oxygen saturation of 92% on room air. Her BMI was 18.8 kg/m2. Physical examination was significant for an ill-appearing female with generalized weakness and mild respiratory distress. She did not have any cardiac murmurs, her lungs were clear to auscultation, and she did not have any rashes. The most pertinent laboratory findings included leukocytosis (14.31 k/uL), normocytic anemia (9.7g/dL), elevated alkaline phosphatase (578U/L), and elevated C-reactive protein (13.38 mg/dL). CT chest/abdomen/pelvis with contrast revealed severe diffuse miliary lung disease, mild bilateral hilar adenopathy, a large pericardial effusion, and ill-defined bony lesions throughout the entire skeleton. CT head without contrast showed multiple calcifications scattered throughout the brain. Given the typical miliary pattern and concern for disseminated tuberculosis, she was empirically started on RIPE therapy. Pericardiocentesis was urgently done due to finding of large circumferential effusion on transthoracic echocardiography concerning for tamponade physiology. The cytology from the pericardial fluid was suspicious for malignancy. Iliac bone biopsy ultimately confirmed metastatic adenocarcinoma consistent with lung primary. RIPE therapy was discontinued, and the patient was started on carboplatin and pemetrexed. After significant improvement in functional capacity, the patient was discharged home with her family after 31 days in the hospital. She is currently being treated with pembrolizumab and pemetrexed and her disease burden has remained stable for 9 months now.

Lung cancer is extremely rare in young adults <35 years old. In this population, it predominantly presents as non-small cell lung cancer (NSCLC) or more specifically, as adenocarcinoma. While cough is the most common presenting symptom (50-75%) in older patients, non-specific symptoms mimicking other pathologies are often present in younger patients with NSCLC. The most common gene mutations are EGFR, KRAS, FGFR1 and ALK, not necessarily hereditary.

Miliary pattern of lung disease can be seen in a handful of etiologies. These include infectious diseases such as tuberculosis and disseminated fungal infections, autoimmune diseases like sarcoidosis, environmental diseases such as silicosis, and neoplastic diseases such as adenocarcinoma and metastasis. The most common of these, as expected, is tuberculosis. In a young patient without risk factors presenting with symptoms and findings typical of an infectious process, we need to be vigilant of less common, unexpected etiologies and keep a broad differential.

Miliary Disease in a 24-year-old Female- An Unexpected Diagnosis

Background
Malaria in the United States is a rare disease with a reported number of cases typically 2,000 each year. In 2022, the State of Ohio had 32 malaria cases: 10 females and 22 males. This mosquito born illness poses a major threat to American travelers, military personnel, and US citizens living abroad in endemic areas. In returning travelers from high-risk countries, Malaria is the most common cause of febrile illness. Plasmodium ovale can remain dormant in the liver and presentation will be delayed. Chronic infection and relapsing disease will persist if the infection is not treated in the initial stages. Relapse episodes may occur months or years later. 

Case Presentation
We present a case of a 39-year-old male with a past medical history of chronic pancreatitis, depression, type 2 diabetes mellitus, gastroesophageal reflux disease, recent Epstein- Barr virus infection, who presents with fever, nausea, and vomiting beginning 10 days prior to admission. The patient has an extensive travel history abroad and returned from Angola six months ago. Prior to admission, he underwent treatment at a different hospital for sepsis, encephalopathy, fever, Epstein-Barr virus and babesia. His condition worsened and he left against medical advice and opted to seek treatment at our facility. With concern for malaria, immediate testing included: Giemsa-stained peripheral blood smear and malaria polymerase chain reaction. His anti-malarial treatment regimen included artemether-lumefantrine tablets for 3 days. Plasmodium species PCR was positive for Plasmodium ovale. The patient responded well to therapy, and continued follow-up at the infectious disease clinic. Likely, the progression and severity of his malaria infection progressively worsened due to delays in treatment and testing. Given his travel history, a concern for malaria should have been on the differential diagnosis at his previous hospital admission.

Discussion
Plasmodium ovale and Plasmodium vivax infection can remain dormant for months and will cause relapses despite anti-malarial prophylaxis treatment. An immunocompromised patient with infection can trigger nonspecific host defense mechanisms. The patient’s symptoms were initially attributed to Epstein-Barr virus infection; unfortunately, there was a missed malaria diagnosis. New research suggests climate change is increasing the mosquito population worldwide and likely causing higher malaria cases. Anti-malarial prophylaxis should be initiated and completed in patients traveling to endemic regions. Returning travelers with flu-like symptoms should be evaluated for malaria as soon as possible.


A Case of Plasmodium Ovale Malaria Presentation

Background
Shigella is a Gram-negative, facultative anaerobic bacteria that causes a gastrointestinal infection characterized by bloody diarrhea. First-line treatment is azithromycin; however, in the men who have sex with men (MSM) population, Shigella is known for higher rates of azithromycin resistance. Other treatments, including trimethoprim-sulfamethoxazole, fluoroquinolones, and ampicillin, are also increasing in resistance. 

Glucose-6-Phosphate Dehydrogenase (G6PD) is an enzyme that prevents cellular damage from reactive oxygen species (ROS), to which red blood cells are especially susceptible. G6PD-deficiency is an inherited disorder characterized by acute hemolytic anemia after exposure to high levels of ROS from foods and certain antibiotics, including many that are used for treatment of Shigella.

Case Presentation
A healthy 28-year-old male with a history of MSM activity presented to the emergency department (ED) with four days of 15-20 daily episodes of increasingly bloody diarrhea and a recent exposure to a sick contact with similar symptoms. As an Active Duty Sailor, he initially sought care from his ship’s physician who prescribed azithromycin and acetaminophen without relief. In the ED, he was tachycardic and physical exam revealed tenderness of left abdominal quadrants with rebound. Rectal exam showed bright red blood and watery brown stool. Lab work was notable for leukocytosis, acute kidney injury (BUN 40, Cr 3.3), and lactate 2.1. A CT abdomen/pelvis revealed moderate proctocolitis. He reported no known drug allergies, and was given fluids, ciprofloxacin 500 mg, and metronidazole 500 mg for presumed infectious diarrhea. He was admitted to the Internal Medicine Ward, where GI Stool PCR resulted positive for Shigella. Chart review indicated a history of G6PD-deficiency, at which point he was transitioned to ceftriaxone from ciprofloxacin with an Infectious Disease consult. He clinically improved and was discharged home on Augmentin; however his symptoms did not resolve on Augmentin. Culture sensitivities resulted after his discharge, which demonstrated resistance to ampicillin. He was switched to cefpodoxime per Infectious Disease recommendation and recovered fully.

Discussion
This case illustrates the value of complete history gathering in determining a patient’s full spectrum of risk factors. Relevant for this patient was his sexual history and medication intolerances that he did not initially disclose. It also highlights the growing importance of alternative treatment regimens to mitigate the adverse effects of increasing global rates of antibiotic resistance, especially for patients with complex histories and medication intolerances.

Diarrheal Dilemma: G6PD-Deficiency Complicating Treatment of Antibiotic- Resistant Shigella in the MSM Population

Background: The WHO reported 132 million cases and 2.8 million deaths from COVID-19 through 2021, with severe cases resulting in multi-organ failure. The Sequential Organ Failure Assessment (SOFA) score measures multi-system organ failure changes overtime. The ability to predict outcomes of critically ill COVID-19 patients would advance allocating resources, better managing this disease. To combat mortality, many potential therapies were studied to manage COVID-19’s lethal effects, one being Azithromycin. While it is safe as treatment for bacterial infections, its effectiveness as treatment for COVID-19 is controversial. Given risks associated with blanket antibiotic use, we sought to evaluate azithromycin’s effectiveness as treatment for COVID-19.

Methods: This is a retrospective, non-controlled, two-center study of consecutive adult (age >18) COVID-19 positive cases admitted at two hospitals in Ventura, California from March 2020 to March 2021. We aim to determine the effect of Azithromycin therapy on SOFA scores, hospital stay duration, and mortality among ICU COVID-19 patients.

Results: 857 patients were admitted between two hospitals for the study period. 46% (N=392) received treatment for COVID-19. 37.8% received Azithromycin as a therapy exclusively or as combination. In the treatment group (N=148), mean age was 57.58±18.70, mean BMI was 31.75±9.1, mean length of stay was 8.26±7.37 days, mean minimum O2 saturation was 79.44±15.26, and mean peak SOFA score was 3.21±3.80. There were 99 (67%) males and 49 (33%) females (P<0.01). 96 (65%) patients self-identified as Hispanic/Latino (P<.01); 62 (42%) were admitted to the ICU. The mortality rate for the treatment group was higher compared to control, but not significantly (17.6 vs. 10.7, P=0.06). Peak SOFA scores were significantly different in the treatment group between those who survived and those who did not (3.9 vs, 10.7, P<0.01).

Conclusion: Azithromycin’s effectiveness at reducing inflammatory markers made it a prominent treatment contender for tempering the COVID-19 cytokine storm, along with data suggesting azithromycin effects viral integration and replication in vitro(10). We found no significant benefit from use of azithromycin in COVID-19 patients. However, despite the treatment group being smaller than control, mortalities were equal. Though not statistically significant, higher mortality was seen after administration of azithromycin to COVID patients. Like other studies, we found no association between the use of Azithromycin in COVID-19 patients and mortality, length of hospital stay, or need for mechanical ventilation(8, 9). Given risk from antibiotic use in large populations without significant benefit, we recommend against the use of azithromycin in COVID-19 patients.

Azithromycin Therapy and its Correlation to the Sequential Organ Failure Assessment, Intensive Care Admission, and Mortality among Hospitalized COVID Positive Patients

Background: America is in the midst of an epidemic of sexually transmitted infections (STI). Between 2020-2021, the CDC reported a 32% increase in the incidence of primary/secondary (early) syphilis with underserved and marginalized communities predominantly affected. Treponemal central nervous system (CNS) invasion is estimated to occur in approximately 25-60% of cases, however, the current standard of care for early syphilis does not achieve CNS clearance. This raises concern for a preventable burden of neurologic morbidity secondary to treponemal CNS persistence and subsequent neurosyphilis. Our central hypothesis is that individuals with history of syphilis infection will experience greater odds of neurologic morbidity relative to their uninfected counterparts. 

Methods: An FQHC-based, preliminary 10-year retrospective analysis (01/2013-12/31/2022) of deidentified electronic medical records (EMR) was undertaken in summer of 2023. The exposure of interest consisted of grouped ICD-10 codes representative of early syphilis infection with neurologic outcomes defined as ICD-10 diagnoses reflective of the principle clinical manifestations of neurosyphilis. Unadjusted, bivariate analysis was performed for preliminary assessment of exposure-outcome association.

Results: 3,711,053 EMR from an academic health system were included in final analysis. 5,981 patients were found to have a diagnosis of syphilis. Patients with syphilis exposure had significantly higher odds for stroke (OR = 5.14; 95%CI = 4.71-5.61), dementia (OR = 20.68 ; 95%CI = 19.27–22.19 ), sensorineural hearing loss (OR= 5.75; 95% CI= 5.07-6.2), and blindness (OR= 15.74 ; 95%CI = 14.31-16.54) relative to unexposed patients. 

Conclusion: Syphilis infection was associated with significantly increased odds of neurologic morbidity across all representative outcome measures queried. These data are concerning as they suggest a clinically significant limitation to the current standard of care for early syphilis. We plan to more rigorously evaluate our hypothesis in a follow-up study that will utilize regression analysis to determine the independent effect of syphilis exposure adjusting for multiple confounders.


An Imitation Game: Syphilis Infection and Increased Odds of Neurologic Morbidity

Background: Pulmonary nodules pose a significant diagnostic challenge in clinical practice. These small, often asymptomatic lesions can be benign or malignant, necessitating accurate localization and sampling for appropriate management decisions. Traditional bronchoscopic procedures have limitations in reaching peripheral lung nodules, particularly in challenging locations. Shape-sensing robotic-assisted bronchoscopy, utilizing the IonTM Endoluminal System, has emerged as a potential breakthrough in the field of pulmonary nodule management. This cutting-edge technology combines advanced imaging, robotic control, and shape-sensing capabilities to enhance the precision and efficacy of bronchoscopic procedures. By providing real-time 3D mapping and navigation guidance, it allows physicians to accurately locate and biopsy pulmonary nodules, even in challenging anatomical regions.
However, despite its promising potential, there is still a knowledge gap regarding the experience and outcomes of using shape-sensing robotic-assisted bronchoscopy for pulmonary nodules. This study aims to bridge this gap by investigating the real-world experiences and outcomes of this innovative technology as a solution for accurate pulmonary nodule management.
Methods: A retrospective analysis was conducted using NVivo software at Chandler Regional Medical Center. The analysis focused on patients who underwent shape-sensing robotic-assisted bronchoscopy for pulmonary nodules. Patient demographics, nodule characteristics, procedural details, diagnostic yield, complications, and overall effectiveness were assessed using NVivo.
Results: A total of 9 patients (5 males, 4 females) with suspected lung nodules were included in this NVivo retrospective analysis. The mean age of the patients was 71.3 years (range: 60-77). The commonly involved lobes were the left upper and lower lobes, and the right upper and middle lobes. The sizes of the nodules ranged from 0.3 cm to 3.2 cm. Needle and forceps biopsies were the most common techniques used for tissue sampling, followed by bronchoalveolar lavage (BAL). Positive findings included malignancy (adenocarcinoma), hamartoma, inflammation, infection, and cellular abnormalities. Negative findings indicated the absence of carcinoma, granulomas, malignancy, fungal organisms, and acid-fast bacteria. One rare case of Mantle cell lymphoma, presenting as a cavitary lesion in the lung, was also diagnosed.
Complications were observed in 2 cases, including small pneumothorax, which were appropriately managed. The analysis also revealed gender differences in complications, with females experiencing pneumothorax and minimal bleeding, while males only suffered minimal bleeding.
Conclusion: This study unveils the transformative potential of shape-sensing robotic-assisted bronchoscopy to enhance diagnostic accuracy and reduce complications. This cutting-edge approach
revolutionizes medical practice, empowering physicians with precise tools while minimizing interventions.

Unleashing Precision: Shape-Sensing Robotic-Assisted Bronchoscopy for Pulmonary Nodules

Background
Alpha-1 Antitrypsin Deficiency (AATD) is an underrecognized genetic condition affecting an estimated 1 in 2,000 to 1 in 5,000 individuals worldwide, with approximately 70,000 to 100,000 cases reported in the United States. Alpha-1 Antitrypsin (AAT) plays a crucial role in protecting the lungs by inhibiting the activity of neutrophil elastase (NE), but in cases of AAT deficiency, uncontrolled NE activity can lead to lung damage through quantum proteolysis. Recurrent spontaneous pneumothorax is a significant complication observed in patients with underlying lung diseases like AATD and chronic obstructive pulmonary disease (COPD). The association between AATD and spontaneous pneumothorax remains relatively unexplored, presenting unique challenges in managing recurrent pneumothorax in these patients. This case report aims to provide valuable insights into the clinical features, diagnostic workup, and therapeutic interventions and associated challenges in managing a patient with recurrent spontaneous
pneumothorax in the context of AATD and COPD, with the objective of offering diagnostic and therapeutic considerations for similar cases.

Case Presentation
61 yo M with A1AT deficiency with severe bullous disease, no known cirrhosis, OSA intolerant of CPAP, hx of recurrent Lt pneumothorax and associated COPD presented with dyspnea. Examination revealed absent lung sounds on the left side. Oxygen support was initiated, and a chest x-ray confirmed left-sided pneumothorax. The patient underwent a successful left-sided pigtail catheter placement procedure to relieve the pneumothorax. This was his fourth episode of Secondary Spontaneous Pneumothorax. Two episodes occurred when he was younger, and the most recent two episodes required the implantation of a left chest tube. The very last episode
appeared on 5/2021. The patient's history of heavy smoking, substance abuse, and occupational asbestos exposure contributed to the severity of respiratory issues. Although his condition improved with pulmonary rehabilitation and medical therapy, the limitations of available interventions underscore the need for individualized approaches in complex cases. Lung volume reduction surgery and endobronchial valves were not viable due to extensive lung involvement and airway hyperdynamic collapse. The recommendation for lung transplantation aimed to enhance the quality of life and life expectancy. Pleurodesis emerged as a potential option if transplantation was not feasible. Further investigations were conducted for the transplant workup, leading to approval by the Medical Review Board. Following the successful placement of the Heimlich valve, the patient was discharged with instructions for outpatient follow-up.

Discussion
This case emphasizes the association between AATD and Recurrent secondary spontaneous pneumothorax, bringing attention to the difficulties encountered in the management of this condition. Further research is needed to optimize treatment approaches, explore the efficacy of alternative interventions, and understand long-term outcomes in this complex patient population.

Alpha-1 Antitrypsin Deficiency Unleashed:
A Case Report On Tackling Recurrent Secondary Spontaneous Pneumothorax

Background
Hypertonic saline is a mainstay treatment of cerebral edema in neurological emergencies. The risk of acute kidney injury (AKI) with use of balanced versus unbalanced hypertonic saline solutions is equivocal across studies. Hypertonic sodium acetate (NaOAc) instead of hypertonic sodium chloride (NaCl) has been used as an alternative to prevent renal injury, with little evidence supporting this. We evaluated patients receiving either NaCl or NAOAc to evaluate the risk of development of AKI.

Methods
We performed a retrospective analysis of patients admitted to our neuroscience ICU from June 2013 to February 2023 who have received continuous intravenous infusions of either NaCl or NaOAc at either 2% or 3% concentration for therapeutic hypernatremia. We excluded patients receiving renal replacement therapy, patients who expired within 24 hours of administration of hypertonic saline, and those receiving treatment for hyponatremia. Renal injury was based of KDIGO criteria (elevation in serum creatinine greater than 0.3 mg/dL within 48 hours of starting intravenous infusion).

Results
Out of 1133 patients who received hypertonic saline, 880 met study inclusion criteria, with 812 patients receiving NaCl and 68 patients receiving NaOAc. Of these patients, 30.4% had acute ischemic strokes, 29.7% had intracerebral hemorrhages, 15.0% had subarachnoid hemorrhages, and 24.9% had other intracranial pathologies. 399 (38.5%) of the patients were female. 79 patients (9.7%) receiving sodium chloride developed AKI, while 11 patients (16.2%) receiving sodium acetate developed an AKI (X2 = 2.8408, p = 0.092) within 48 hours of initiation of intravenous therapy. 

Conclusion
Contrary to some reported observations, we found no statistical difference in the development of AKI as defined by KDIGO criteria in patients treated with NaCl versus NaOAc. Our study is limited by a small subset of patients receiving NaOAc. A larger cohort is needed to establish the protective effect of balanced hypertonic saline on AKI.

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Cognitive Dissonance: Why Do Language Model Outputs Disagree with Internal Representations of Truthfulness?

Unusual presentation of sore throat with bilateral lymphadenopathy in a hypothyroid patient: Kikuchi Fujimoto Disease, A case report.

Efficacy of N-Acetyl Cysteine in the Prevention of Post-Operative Atrial Fibrillation and Acute Kidney Injury Post-Cardiac Surgery: A Systematic Review

Title of Persistent Miller Fisher Syndrome Following COVID-19 Infection: A Case Report

Miliary Disease in a 24-year-old Female- An Unexpected Diagnosis

A Case of Plasmodium Ovale Malaria Presentation

Diarrheal Dilemma: G6PD-Deficiency Complicating Treatment of Antibiotic- Resistant Shigella in the MSM Population

Azithromycin Therapy and its Correlation to the Sequential Organ Failure Assessment, Intensive Care Admission, and Mortality among Hospitalized COVID Positive Patients

An Imitation Game: Syphilis Infection and Increased Odds of Neurologic Morbidity

Unleashing Precision: Shape-Sensing Robotic-Assisted Bronchoscopy for Pulmonary Nodules

Alpha-1 Antitrypsin Deficiency Unleashed: A Case Report On Tackling Recurrent Secondary Spontaneous Pneumothorax

Effects of Balanced Versus Unbalanced Hypertonic Saline on Renal Function in Neurocritical Care

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