In malignant pleural effusion (MPE), malignant cells may settle in a gravity-dependent gradient due to the weight of cells. We aimed to compare diagnostic yield of cytology between aspirates from lower, upper and 5th intercostal spaces in suspected malignant moderate to massive effusion under transthoracic ultrasound guidance (TUS). This single-center, analytical, cross-sectional study was conducted over 6 months. 62 subjects with suspected MPE having moderate to massive effusion on TUS were asked to either sit or recline on bed at 45 - 900 inclination for 2 h. Under TUS guidance, diagnostic thoracentesis was done from lowermost space (2 intercostal spaces [ICS] above the level of diaphragm), uppermost space (1-2 ICS below highest level) and triangle of safety. Diagnostic yields for malignancy on cytology were compared between three sites. 36 subject's cytology returned positive for malignancy. The median lowest and highest ICS of aspiration was 7th and 4th ICS respectively. Lower space aspirate showed higher positivity (88.9%) compared to upper space (58.3%; Mcnemar critical value 3.84, p = 0.013). It showed poor agreement (k = -0.085 p = 0.473) to upper space and moderate level (k = 0.321, p = 0.025) with mid axillary line aspirate (72%, n = 26). Lung malignancies showed better lower space aspirate positivity than extra-pulmonary (p = 0.018). Pleural nodule, central/peripheral lung mass and cancer sub-type did not affect the diagnostic yield. No complications were noted in any subject. Diagnostic thoracentesis from lower ICS may provide higher cytological yield in suspected MPE, however, this must be done only under TUS guidance to prevent complications.

Background: This study aimed to estimate the proportion of presumptive pulmonary tuberculosis (PTB) cases lost to follow-up (LTFU) before diagnosis at a tertiary care facility and explore associated factors. Methods: A mixed-method study (sequential explanatory, QUAN-qual) was conducted at the pulmonary Outpatient Department of a tertiary care institute from November 2022 to June 2023. Quantitative data were collected using a semi-structured questionnaire and analyzed with IBM SPSS trial version 25. Qualitative data were obtained through in-depth interviews using the Health Care Access Barriers model. Results: Out of 160 cases, 63.7% were males, and 84.4% underwent sputum testing. The qualitative findings highlighted structural, financial, and cognitive constraints causing diagnostic delays. A total of 15.6% of pulmonary Tuberculosis (TB) cases were LTFU before diagnosis. Conclusion: This study revealed significant pretreatment LTFU in pulmonary TB cases, influenced by factors such as healthcare access, socioeconomic status, literacy, and societal norms.

INTRODUCTION:Compared with other types of central nervous system tuberculosis (TB), meningeal TB has a greater fatality rate. However, data on mortality predictors are limited. This study aimed to determine predictors of mortality in patients with meningeal TBM. STUDY DESIGN:This was a hybrid retrospective-prospective (ambispective) study, in which data were collected retrospectively for patients admitted between January 2019 and December 2020 and prospectively for patients admitted between January 2021 and March 2022. MATERIALS AND METHODS:We conducted an ambispective cohort study of 132 adults (>18 years) with suspected meningitis admitted to the All India Institute of Medical Sciences, Rishikesh, India, between January 2019 and March 2022. Patients were classified as having definite, probable, or possible tuberculous meningitis (TBM) using the Lancet Consensus case definition. The primary outcome was in-hospital mortality. Univariable and multivariable Cox proportional-hazards models were used to identify predictors. RESULTS:Of the 132 patients enrolled in the study, 66 were classified as having definitive TBM, 12 as probable TBM, 21 as possible TBM, and 33 as non-TBM. The overall mortality rate among patients with any form of TBM (definitive, probable, or possible) was 37.87% (25 deaths), with the highest mortality observed in the definitive TBM group, accounting for 32.3% of deaths (21 cases). Fever, altered sensorium, high serum neutrophil count, low serum lymphocyte count, high CSF lymphocyte count, and low CSF neutrophil count were significantly associated (p<0.05) with the variable definitive TBM as a predictor of mortality in our study. CONCLUSIONS:Simple hematological and CSF parameters can help stratify risk in TBM. These markers may guide early clinical decisions and closer monitoring.

BACKGROUND AND OBJECTIVES:Obstructive sleep apnea (OSA) is associated with an increased risk of cardiometabolic disorders. Still, the role of OSA duration in the development and severity of these conditions remains unclear. This study aimed to evaluate the association between estimated OSA duration and cardio-metabolic comorbidities. MATERIALS AND METHODS:In this cross-sectional study, 279 adults (≥35 years; body mass index ≥20 kg/m 2 ) with moderate-severe OSA diagnosed by level-1 polysomnography were included. Diagnosis of cardiometabolic disorders was based on examination, medical records, and laboratory investigations. Duration of OSA was estimated using the OSA-Onset algorithm, and comorbidity prevalence was compared across tertiles of estimated duration. RESULTS:In this cross-sectional exploratory analysis, the median estimated OSA duration was 18.7 years, and the median estimated age of onset was 32.3 years. Systemic hypertension was the most prevalent comorbidity (79.6%) and showed a higher prevalence across tertiles of estimated OSA duration (68.8%, 83.9%, and 86%, respectively; P = 0.007). In multivariable models, estimated OSA duration was statistically associated with hypertension (odds ratio [OR] 1.039, 95% confidence interval [CI] 1.012-1.068; P = 0.005). Sensitivity analysis excluding participants with implausible negative onset estimates yielded similar results (OR 1.036, 95% CI 1.006-1.066; P = 0.017). No statistically significant associations were observed for other cardiometabolic conditions. Given multiple comparisons and correlated outcomes, findings should be interpreted as exploratory. CONCLUSION:In this cross-sectional exploratory study, longer algorithm-estimated OSA duration was statistically associated with hypertension but not with other cardiometabolic comorbidities. These findings are hypothesis-generating and require confirmation in longitudinal studies.

Background:In certain parts of the world, the use of drones in health care is expanding to increase outreach and accessibility of health services. In India, states located in the Northern Himalayan region of the country have predominantly hilly and challenging topography, making it difficult to deliver medications and medical samples on time. Methods:In the current study, initiatives for the use of drone technology in medicine were put into practice through a sequence of proof-of-concept trials that were conducted in a tertiary care facility in India to deliver antitubercular medications and blood products in the hard-to-reach terrain of the Himalayas and the transportation of samples to the laboratory. Results:A total of seven trials were conducted, which represent seven sorties, including round trips. Of these, five trials were successful while two trials failed due to environmental challenges. The trial's findings indicate that employing drones can reduce medicine delivery time and sample turnaround times in laboratories comparatively faster than conventional transportation methods (Google Map estimated driving times (minutes) (EDTs) [Median (Range) 130 (46-165] vs drone delivery times (DDTs) [Median (Range) 34 (16 - 35); p = 0.009) in hilly terrain. Administrative, meteorological, and technological challenges were encountered during drone operations. Conclusion:Drones can enable faster access to medical supplies, especially in remote locations.This study evaluated the feasibility and challenges involved in using drones to deliver medical supplies in hilly terrain areas.

Aims: Studies regarding predictors of mortality among stable chronic obstructive pulmonary disease (COPD)patients are limited, with existing data suffering from heterogeneity in terms of the study population, parameters analysed and results, necessitating generalisation from data of high-income countries. This longitudinal observational study aims to analyse factors responsible for 5-year all-cause mortality among stable COPD patients from a single tertiary care centre in India. Methods: Spirometry diagnosed stable COPD patients were contacted telephonically at the end of 5 years, and the outcome was recorded as alive or dead based on telephonic response. Demographic details including age, sex, residence, smoking status, body mass index (BMI), spirometric indices, six-minute walk distance, combined assessment, modified Medical Research Council dyspnea scores, presence or absence of anxiety/depression, history of previous hospitalisation was available at baseline. Results: Out of 130 participants at baseline, 75 responded telephonically, with a mortality rate of 26.6% among the 75 subjects. BMI and combined assessment demonstrate a significant association with mortality and fare better than the demographic variables, multivariate indices and spirometric severity on univariate and multivariate analysis. Conclusion: BMI is a better predictor of mortality among COPD patients than other demographic characteristics. Combined assessment is not only a tool for initial stratification and treatment initiation but also has prognostic utility in stable COPD patients and fares better than other clinical characteristics

Background:The potential role of aerosol drug therapy (ADT) in patients with acute respiratory distress syndrome (ARDS) remains uncertain. The objective of this study is to determine the prevalence and practice patterns of ADT in patients with ARDS. Methods:This secondary analysis of a prospective observational multi-centric cohort study done in critically ill patients to know the ADT practice pattern was conducted in nine participating intensive care units (ICUs) across India between November 2022 and March 2023. The study recruited newly admitted adult patients (age >18 years) who had an artificial airway and required mechanical ventilation (invasive or non‑invasive). These patients were followed up for the next 14 days or until ICU discharge or death. This secondary analysis collected data about screened patients with ARDS, related to each aerosol therapy including ongoing respiratory support, type of drug, and aerosol‑generating device, including ongoing respiratory support, type of drug, and aerosol‑generating device. Results:Fifty-three (24.3%) of the 218 patients had ARDS, with a mean age of (60.2±14.8) years. At admission, the acute physiology and chronic health evaluation (APACHE II) and sequential organ failure assessment (SOFA) score of the recruited patients were 17.4±7.1 and 7.7±4.0, respectively. Respiratory support was provided with invasive mechanical ventilation (IMV) alone, non-invasive ventilation (NIV) alone, or both in 45.3%, 24.5%, and 30.2% of patients, respectively. The mean duration of the ICU stay was (6.4 ± 4.0) days. Of the 53 patients with ARDS, 51 (96.2%) received 1285 aerosol sessions during follow-up for 330 patient days. Of all patients with ARDS who received aerosol therapy, 71.4% were prescribed while on IMV and 25.7% on NIV. A single drug was used in 60.7% of the aerosol sessions used a single drug, and 39.3% were prescribed combination drugs. Shorter-acting bronchodilators were the predominant drugs, with jet nebulizers (55.4%) being the most commonly used aerosol generators. These were followed by ultrasonic (23.1%) and vibrating-mesh nebulizers (21.5 %). During IMV, only in 50.1% of aerosol sessions (460 out of 918) was an aerosol generator placed at the optimum position (15-30 cm away from the Y-junction). Conclusions:Aerosol therapy is frequently used in ARDS, with bronchodilators being the most common drug. The jet nebulizer is the most familiar aerosol-generating device, but only half of the aerosol sessions are at the optimum position during invasive mechanical ventilation.

BACKGROUND:Fever of unknown origin (FUO) remains a diagnostic challenge and was originally defined in 1961. Its classic criteria include fever ≥ 38.3 °C (≥ 101 °F) on multiple occasions, fever lasting three weeks or longer, and a diagnosis after one week of inpatient evaluation. However, these criteria may not fully encompass the varied clinical presentations seen in resource-limited settings such as India. The adaptation of FUO definitions to local healthcare contexts is crucial for enhancing diagnostic accuracy and optimizing patient outcomes. AIM:To investigate the applicability of revised FUO criteria in a tertiary care setting in India. METHODS:This longitudinal-exploratory study at All India Institute of Medical Sciences Rishikesh (January 2018-December 2022) analyzed 228 adult patients with fever ≥ 99.1 °F lasting over three days. Patients diagnosed within three days of admission were excluded. Data were collected retrospectively and prospectively using predefined FUO definitions based on durations of nondiagnosis (3-21 days, > 21 days), temperature ranges (99.1 °F-100.9 °F, ≥ 101 °F), and hospitalization durations (3-7 days, > 7 days). Descriptive statistics and comparative tests (Fisher's exact test, χ 2 test) evaluated outcomes across definitions. RESULTS:Among the proposed FUO definitions, Definition B (fever lasting 3-21 days, temperatures between 99.1 °F-100.9 °F, hospitalization > 7 days) predominated (40.8%), while only 2.2% met the classical criteria. Notably, 36.5% of Definition B patients remained undiagnosed after 7-10 days, despite 94% undergoing diagnostic workups within 21 days. Infection emerged as the leading etiology across definitions, without significant variation in outcomes or mortality during hospitalization (χ 2 = 27.937, P = 0.142). CONCLUSION:Adapting FUO criteria to local contexts improves diagnostic accuracy and treatment. Definition B (40.8% prevalence) showed practical utility, with higher mortality in patients discharged on empirical 'Anti-tuberculosis therapy'.

Chronic obstructive pulmonary disease (COPD) is a major cause of morbidity and mortality throughout the world. The coexistence of COPD and obstructive sleep apnea (OSA) (i.e., overlap syndrome) has been reported in several studies. Both disorders independently increase the risk of cardiovascular complications. Hence, there is a theoretical possibility that cardiovascular parameters may be worse in patients with overlap syndrome compared to those with only COPD. However, this has been sparsely assessed in the literature. This study aimed to compare the clinical characteristics, echocardiography, and sleep parameters amongst COPD patients with and without sleep-related breathing disorders (SRBD). This observational, cross-sectional study included 30 patients with stable COPD. All participants underwent a detailed clinical evaluation, followed by level 1 polysomnography (PSG). Each participant underwent echocardiographic evaluation to estimate mean pulmonary artery pressure from right ventricular systolic pressure (RVSP). Based on their PSG findings, participants were classified into non-SRBD and SRBD groups. Both groups were further compared with respect to clinical characteristics, echocardiographic, and PSG parameters. We found that most of the participants (93.3%) were male, and the mean age of the study population was 56±8.2 years. The only SRBD identified in this study was OSA, which was observed in 80% of participants. In this group, OSA was not associated with obesity. Systemic hypertension (50%) was the most common comorbidity, followed by diabetes mellitus (26.67%), but both were not significantly different between the groups. The mean RVSP was significantly higher amongst OSA patients than non-OSA patients (41.25±14.98 versus 30.83±5.84, respectively; p=0.01). OSA was seen in 80% of participants with stable COPD, even in the absence of obesity. The presence of OSA was associated with a higher RVSP in this patient group.

Limited studies have examined the prevalence of restless legs syndrome (RLS) among patients with chronic obstructive pulmonary disease (COPD) including its correlates and impact, with varying results suggesting a need for systematic review and meta-analysis to address this important issue. Despite a careful search by authors, a systematic review and/ or meta-analysis was not found and hence, present study was planned. To address the research question, a systematic literature search was carried out with the keywords “RLS” OR “restless legs syndrome” AND “COPD” OR “chronic obstructive pulmonary disease” OR “COAD” OR “chronic obstructive airway disease” in three databases: Pubmed, Scopus and Google Scholar between 8th June 2021 to 20th July 2021. A total of 69,298 articles were found across these databases. Studies were included if they had assessed proportion of RLS with or without control group in human subjects suffering from stable COPD as the primary end-point, assessment of RLS was done through clinical diagnosis or a screening tool, sample size was greater than 30 and studies published in English language. Total eight studies were included in the meta-analysis with a total of 10,749 participants in cross sectional studies. Meta-analysis suggested that patients with COPD have higher prevalence of RLS compared to control population or prevalence in general adult population (Cumulative log OR = 4.86; 95

Lung cancer is the most common neoplastic disorder associated with paraneoplastic syndromes. The most common paraneoplastic syndromes are the syndrome of inappropriate release of antidiuretic hormone (SIADH), hypercalcemia of malignancy, ectopic Cushing's syndrome, and various other neurological syndromes. A few case reports have reported gynecomastia as a paraneoplastic syndrome. Recognition of this uncommon presentation can aid in the early detection of associated malignancies, thus potentially improving outcomes. In this article, we are presenting the case of a male patient in his late sixties who, on presentation, had gynecomastia and was eventually diagnosed with non-small-cell lung cancer (NSCLC).

Background Pulmonary rehabilitation (PR) is an integral part of non -pharmacological therapy in chronic obstructive pulmonary disease (COPD). Yoga therapy (YT) has been shown to be beneficial in COPD, but the lack of large well -designed trials and standardized modules restricts its acceptability. This randomized control trial compares these two modalities in COPD patients via supervised tele -intervention. Objectives The primary objective of the study is to compare a 45 -minute, five -days -per -week series of tele -YT (T -YT) with tele -PR (T -PR) for three months in terms of exercise capacity (6 -Minute Walk Distance (6MWD)) in COPD patients. Methods COPD patients were randomly assigned (1:1) to T -YT or T -PR groups in a parallel -arm single -blinded controlled trial. The primary outcome is 6MWD recorded at baseline and after three months and secondary outcomes were symptom scores, Forced expiratory volume in the first second (FEV1), health -related quality of life (HrQoL), and depression and anxiety scores. Assessments were conducted at baseline and at the end of the three-month study period with a sample size of 75 in each group. Results A total of 150 consecutive patients with COPD were randomly assigned to either the T -YT (n = 75) or T -PR (n = 75) group. Their mean +/- SD ages was 62.5 +/- 7.0 years. The T -YT group had 55.5% males and 34.47% females, whereas the T -PR group had 44.5% males and 61.53% females. The trial was completed by 123 patients; 88% in the T -YT group and 76% in the T -PR group. Pre -intervention, the median (range) of 6MWD in T -YT and T -PR groups was 240 (120-600) m and 240 (120-660) m, respectively. There was statistically significant improvement in both groups respectively (p<0.001) post intervention from baseline but no significant intergroup difference (p = 0.486). A similar trend was seen in secondary outcomes with significant intragroup improvements and non -significant inter -group differences except FEV1%, which showed neither intragroup nor intergroup significant improvement. Conclusion Using a validated module, a three-month T -YT improves exercise capacity, symptom scores, HrQoL, and depression and anxiety scores similar to T -PR. T -YT is an acceptable alternative to T -PR in the management of COPD.

BACKGROUND:In recent years, a significant understanding of delivering optimal aerosol therapy and the availability of various drugs and devices have led to an increase in its use in clinical practice. There are only a few studies available regarding their use in critically ill patients from a few parts of the world. We aimed to study the practice pattern of aerosol therapy in critically ill patients from Indian intensive care units (ICUs). METHODS:After ethical approval, this multi-centric prospective observational study was performed over a study period of four weeks. Newly admitted adult patients considered who had an artificial airway and/or ventilation (including non-invasive). Patients were followed up for the next 14 days or until ICU discharge/death (whichever came first) for details of each aerosol therapy, including ongoing respiratory support, drug type, and aerosol-generating device. RESULTS:From the nine participating centers across India, 218 patients were enrolled. Of 218 enrolled patients, 72.48% received 4884 aerosols with 30.91 ± 27.15 (95%CI: 26.6-35.1) aerosols per patient over 1108 patient days. Approximately 62.7% during IMV, 30.2% during NIV, 2.3% in spontaneously breathing patients with an artificial airway during weaning, and 4.7% were given without an artificial airway after weaning or decannulation. In 59%, a single drug was used, and bronchodilators were the most frequent. The jet nebulizer was the most common, followed by the ultrasonic and vibrating mesh aerosol generator. The ventilator setting was changed in only 6.6% of the aerosol sessions with IMV and none with NIV. CONCLUSION:Aerosol therapy is frequently used with a wide variation in practices; bronchodilators are the most commonly used drugs, and jet nebulizers are the most widely used.

Background: Yoga plays a beneficial adjunctive role in various disorders due to its physiological and psychological benefits. COVID-19 pandemic led to a paradigm shift in delivery of health interventions from on-site to online/ tele-intervention mode. Focus shifted to tele-yoga as a reasonable and feasible alternative to in-person yoga. Studies have evaluated its effect among patients suffering from various disorders, their care givers, healthcare workers, and the general public. We have assessed the effect of tele- Yoga, including its appropriateness, acceptability, and benefits, via this narrative review. Methods: We searched PubMed data base using predefined keywords. Inclusion criteria included controlled trials and Randomized Controlled Trials (RCTs) which are completed and published in English language up to February 2022 with tele-yoga/online yoga as part of intervention. Exclusion criteria included articles in other language or articles whose full text is unavailable. Results: After removing duplications and reviewing articles based on title, abstracts, and available full texts, seven studies with 391 participants were included. Majority of the trials took place in United States, with United Kingdom, Canada, and India following closely behind. Yoga can be safely administered via various online /tele interventions in both diseased and healthy individuls. Tele yoga or modules incorporating tele-yoga has been shown to improve symptoms like dyspnea, psychiatric/psychological burden including stress,anxiety and depression levels and may promote positive effects like spirituality. Conclusion: Tele-yoga is feasible and beneficial in healthy and diseased individuals. Larger well-designed RCTs comparing in-person yoga with tele-yoga are needed to ascertain their full benefits.

Introduction: This study attempts to generate preliminary data regarding post-COVID pulmonary fungal infections, namely, COVID-19-associated pulmonary aspergillosis (CAPA), COVID-19-associated pulmonary mucormycosis (CAPM), and mixed infections from the Himalayas and compares the micro-radio-clinical profile and outcomes of the affected patients. Materials and Methods: A retrospective data analysis was conducted, where clinical profiles, microbiological and radiological reports, and outcomes of n = 16 patients of post-COVID pulmonary infections were compared. Results: Of n = 16 patients, n = 7 had CAPA ( n = 5 Aspergillus fumigatu s, n = 1 Aspergillus flavus, and n = 1 Aspergillus niger ), n = 5 CAPM (Rhizopus arrhizus) , and n = 4 with mixed infections ( n = 3 infected with Aspergillus fumigatus and Rhizopus spp. and n = 1 with Aspergillus flavus and Rhizopus arrhizus ). Thick-walled cavitary lesions, air–fluid levels, and multiple centrilobular nodules were some of the common radiological findings reported among these patients. Conclusion: The immuno-compromised state following COVID-19 infection and treatment might be responsible for the progression of regular exposure to the dense Himalayan vegetation into an invasive pulmonary fungal infection. Suspecting post-COVID pulmonary fungal infection is necessary for primary care physicians to ensure timely referral to higher centers. Mixed pulmonary fungal infections (coinfection with Aspergillus spp. and Rhizopus spp.) are also emerging as important sequelae of COVID-19.

BACKGROUND:SARS-CoV-2 infection that led to the COVID-19 pandemic has changed human health and the economy globally. SARS CoV-2 is a type of Coronaviruses that has caused pneumonia and its complications with many deaths over the past two years. The use of hydroxychloroquine and chloroquine, accepted as generally safe for patients with autoimmune diseases or malaria, was attempted in many trials for COVID-19 treatment. Nigella sativa (NS) (black caraway, also known as black cumin, nigella or Kalonji) is an annual flowering plant of the Ranunculaceae family, chemically composed of the main constituent natural Thymoquinone (TQ) (30%- 48%) in forms of thymohydroquinone, dithymoquinone (Nigellone) is a native to wider regions, including parts of eastern Europe, west Asia, North of Africa and east of Myanmar. In this review, we explored the Randomized Controlled Trial, Controlled Trial, and Systematic review studies that support Nigella sativa Thymoquinone-targeted SARS-CoV-2 targeting. Therefore, A literature search was performed for publications published on the electronic databases (PubMed, Embase, Scopus, CNKI, and Google Scholar) for Nigella sativa, black seeds, Kalonji, coronavirus, SARS-CoV -2 and COVID-19. This review aimed to find relevant evidence of Nigella sativa preferences as a natural feasible remedy with no side effects in COVID-19. Studies reported the benefits of NS as beneficial, another appropriate remedy for patients with COVID-19. However, all studies have shown limitations, such as limiting clinical symptom outcomes due to regulations imposed by isolation policies and lack of adequate funding. Therefore, the evidence suggests that the chemical contents of NS are a safe and possible treatment for COVID-19 patients that helps to improve COVID-19 infection in patients with no side effects.CONCLUSION:Nigella sativa seeds were one of the well-documented herbal products. Three reviewed randomized controlled trials reported that NS reduced covid-19 risk and could improve immune function. It was also helpful in upper respiratory infections such as asthma and bronchitis, with one RCT showing that honey and NS significantly improved symptoms, viral clearance, and mortality of COVID-19 patients. This review concludes that NS has a positive barrier effect on people at risk of acquiring a COVID-19 infection.

AbstractBackgroundFever of Unknown Origin (FUO) is a challenging medical condition characterized by prolonged fever without an identifiable cause despite extensive evaluation. The existing definition, proposed in 1961, requires illness lasting over three weeks, fever of ≥38.3°C (≥101°F) on two occasions, and uncertain diagnosis after one week of inpatient evaluation, excluding immunocompromised patients and in-hospital evaluation. However, the current criteria may not fully capture the diverse spectrum of FUO cases, especially in resource-constrained settings like North India. This study aims to revisit the criteria for FUO in terms of durations of non-diagnosis, temperature ranges, and duration of hospitalization rather than considering the duration of illness and using a set of obligatory investigations. It will propose a more practical and effective approach based on local healthcare resources.MethodsThis study utilized a retrospective and prospective longitudinal-exploratory design and was conducted at a single tertiary care center, All India Institute of Medical Sciences (AIIMS) in Rishikesh, North India. The study population consisted of 228 patients meeting the inclusion criteria from January 2018 to December 2022. Inclusion criteria involved adult patients with documented fever of ≥99.1°F on at least two occasions and fever lasting for more than three days. Exclusion criteria included patients with a definitive diagnosis within three days of hospitalization. Data were collected from the hospital’s MRD section retrospectively and through prospective follow-up of eligible patients. Proposed new definitions for FUO were considered, encompassing different ranges of duration of non-diagnosis (3-21 days, >21 days) temperature ranges (99.1°F-100.9°F and ≥101°F), and durations of hospitalization (3-7 days and >7 days). The frequency of each definition was measured. The etiology and outcomes of patients under each definition were analyzed using appropriate statistical tests.FindingsAmong the proposed definitions, Definition B (fever lasting 3-7 days with temperatures between 99.1°F-100.9°F) had the highest prevalence (40.8%), followed by Definitions A, D, and C. In contrast, only 5 patients (2.2%) met the classical Definition H (in terms of temperature and duration of hospitalization). By closely observing the patients in Definition B group, around 36.5% patient remained non-diagnosed between >7 to 10 days which is highest among the group. Approximately 62% of patients remained undiagnosed before 21 days of hospitalization and initiated treatment, with temperatures ranging between 99.1°F to 100.9°F. The remaining 38% of patients, with temperatures ≥101°F, also remained undiagnosed before commencing treatment. The majority of patients (94%) underwent diagnostic workups and treatment within 21 days of hospitalization, reflecting the importance of early evaluation and intervention.DiscussionThe findings of this study underscore the need for revising the criteria for diagnosing FUO. The prevalence of FUO cases under the proposed definitions suggests that the classical criteria may not fully capture the diverse patient population’s needs and local healthcare resources. The study highlights the importance of a flexible diagnostic timeline, comprehensive clinical assessment, and individualized temperature thresholds to ensure timely and effective care for patients with undiagnosed fever. The lack of significant differences in etiology and outcomes among the various definitions further supports the idea that modifying the criteria can enhance the management of FUO cases without compromising patient outcomes.ConclusionThe study emphasizes the need for a revised approach to defining FUO, taking into account the local healthcare resources and patient population. Adapting the criteria based on temperature ranges and durations can lead to a more practical and effective diagnosis and management of FUO. The proposed flexible diagnostic timeline and comprehensive clinical assessment can improve the timely identification of underlying causes and guide clinicians in providing appropriate treatment and support for patients with undiagnosed fever. Continued research and collaboration within the medical community are essential to develop context-specific guidelines for diagnosing and managing FUO.