Oral self-nanoemulsifying drug delivery systems for enhancing bioavailability and anticancer potential of fosfestrol: In vitro and in vivo characterization.

PURPOSE: The objective of the current research work was to fabricate a fosfestrol (FST)-loaded self-nanoemulsifying drug delivery system (SNEDDS) to escalate the oral solubility and bioavailability and thereby the effectiveness of FST against prostate cancer. METHODS: 32 full factorial design was employed, and the effect of lipid and surfactant mixtures on percentage transmittance, time required for self-emulsification, and drug release were studied. The optimized solid FST-loaded SNEDDS (FSTNE) was characterized for in vitro anticancer activity and Caco-2 cell permeability, and in vivo pharmacokinetic parameters. RESULTS: Using different ratios of surfactant and co-surfactant (Km) a pseudo ternary phase diagram was constructed. Thirteen liquid nano emulsion formulations (LNE-1 to LNE-13) were formulated at Km = 3:1. LNE-9 exhibited a higher % transmittance (99.25 ± 1.82 %) and a lower self-emulsification time (24 ± 0.32 s). No incompatibility was observed in FT-IR analysis. Within 20 min the solidified FST loaded LNE-9 (FSTNE) formulation showed almost complete drug release (98.20 ± 1.30 %) when compared to marketed formulation (40.36 ± 2.8 %), and pure FST (32 ± 3.3 %) in 0.1 N HCl. In pH 6.8 phosphate buffer, the release profiles are found moderately higher than in 0.1 N HCl. FSTNE significantly (P < 0.001) inhibited the PC-3 prostate cell proliferation and also caused apoptosis (P < 0.001) compared to FST. The in vitro Caco-2 cell permeability study results revealed 4.68-fold higher cell permeability of FSTNE than FST. Remarkably, 4.5-fold rise in bioavailability was observed after oral administration of FSTNE than plain FST. CONCLUSIONS: FSTNE remarkably enhanced the in vitro anticancer activity and Caco-2 cell permeability, and in vivo bioavailability of FST. Thus, FST-SNEDDS could be utilized as a potential carrier for effective oral treatment of prostate cancer.

Acute Respiratory Infection Incidence and Outpatient Antibiotic Prescription Patterns in People With or Without Human Immunodeficiency Virus Infection: A Virtual Cohort Study.

Background: Inappropriate antibiotic use in acute respiratory infections (ARIs) is a major public health concern; however, data for people with human immunodeficiency virus (PWH) are limited. Methods: The HIV Virtual Cohort Study is a retrospective cohort of adult Department of Defense beneficiaries. Male PWH cases (n = 2413) were matched 1:2 to controls without HIV (n = 4826) by age, gender, race/ethnicity, and beneficiary status. Acute respiratory infection encounters between 2016 and 2020 and corresponding antibiotic prescriptions were characterized as always, sometimes, or never appropriate based on International Classification of Diseases, Tenth Revision coding. Incidence of ARI encounters and antibiotic appropriateness were compared between PWH and controls. Subgroup analyses were assessed by CD4 count and viral load suppression on antiretroviral therapy. Results: Mean rates of ARI encounters were similar for PWH (1066 per 1000 person-years) and controls (1010 per 1000 person-years); however, the rate was double among PWH without viral load (VL) suppression (2018 per 1000 person-years). Antibiotics were prescribed in 26% of encounters among PWH compared to 34% for controls (P ≤ .01); antibiotic use was "never" appropriate in 38% of encounters with PWH and 36% in controls. Compared to controls, PWH received more sulfonamides (5.5% vs 2.7%; P = .001), and variation existed among HIV subgroups in the prescription of sulfonamides, fluoroquinolones, and ß-lactams. Discussion: Acute respiratory infection encounters were similar for PWH and those without HIV; however, PWH with lower CD4 counts and/or nonsuppressed VL had more frequent ARI visits. Inappropriate antibiotic use for ARIs was high in both populations, and focused interventions to improve antibiotic appropriateness for prescribers caring for PWH should be pursued.

Evaluation of the quality of cardiopulmonary resuscitation provided by the emergency response team at a tertiary care hospital.

Background and Aims: Chest compression fraction is the proportion of time spent on chest compression during cardiopulmonary resuscitation (CPR). The aims of this study were to know the quality of CPR provided during in-hospital cardiac arrest (IHCA) by analysing the chest compression fraction and to see the correlation of chest compression fraction with return of spontaneous circulation (ROSC) in the hospital setting. Methods: This prospective observational study was conducted in patients aged >18 years who developed IHCA. An observer would assess the quality of CPR provided by noting the time spent on chest compression. The chest compression fraction was calculated and correlated in patients with ROSC and without ROSC. Patients who survived were followed until discharge, and their neurological score was determined using the cerebral performance category (CPC). Results: We included 126 patients in the study; the mean chest compression fraction achieved was 78% (standard deviation [SD] ± 5). A total of 73 (58%) patients achieved ROSC and among them, 11 patients (9%) survived to hospital discharge. We found that the patients with ROSC had a significantly higher chest compression fraction of 80% (SD ± 5), as compared to 75% (SD ± 5), in whom ROSC could not be achieved. A multivariate logistic regression test showed higher odds (1.125) of ROSC in patients with high chest compression fraction. The mean CPC among the survivors was 1.4 (SD ± 0.5). Conclusion: Our study shows that health-care providers in our hospital provide high-quality CPR, and chest compression fraction is independently associated with ROSC in IHCA.

Factors associated with erectile dysfunction diagnosis in men with HIV infection: a case-control study.

OBJECTIVES: HIV infection is associated with increased risk of erectile dysfunction (ED); however, factors associated with ED remain unclear. We evaluated the prevalence of ED among men living with HIV and factors associated with ED diagnosis in the US Military HIV Natural History Study (NHS). METHODS: A retrospective cohort study evaluated participants in the NHS, a cohort of HIV-positive active duty members and beneficiaries with HIV infection. Men with a diagnosis of ED after HIV diagnosis were included. Cohort controls without ED diagnosis were matched 2:1 by age at HIV diagnosis and duration of follow-up. Multivariate logistic regression models were used to identify factors associated with ED. RESULTS: A total of 543 of 5682 male participants (9.6% prevalence) had a diagnosis of ED, of whom 488 were included in the analysis. The median (interquartile range, IQR) age at ED diagnosis was 43 (37.0-49.0) years and the time from HIV diagnosis to antiretroviral therapy (ART) start was longer for cases (5.0 years, IQR: 2.0-9.0) than for controls (3.0 years, 1.0-6.0; P < 0.01). Cases had higher proportions of multiple comorbid conditions, including depression (33.4% vs. 21.7%), tobacco use (19.7% vs. 9.0%) and sleep apnoea (14.8% vs. 4.2%) compared with controls (P < 0.01 for all). Logistic regression showed increased odds of ED for delayed ART initiation > 4 years [odds ratio (OR) = 2.05, 95% confidence interval (CI): 1.56-2.71], protease inhibitor use ≥ 1 year (OR = 1.81, 95% CI: 1.38-2.38) and sleep apnoea (OR = 2.60, 95% CI: 1.68-4.01). CONCLUSIONS: Erectile dysfunction was common in men with HIV and associated factors included both HIV-related and traditional factors.

Obstetric anaesthesia as a career.

Obstetric anaesthesia is emerging as one of the most demanding subspecialities of anaesthesia. Obstetric anaesthesiologists are now an integral part of the multidisciplinary team managing the high-risk obstetrics. It has been recognised that targeted training in obstetric anaesthesia helps to recognise the mothers who need special care and formulate specific plan for delivery. Among the subspecialties of anaesthesia, obstetric anaesthesia has the potential to get established early. Obstetric anaesthesiologists have the prospect of choosing either a team or an independent practice. Group practice with a multidisciplinary team can mitigate some of the constraints and allows professional fulfilment and enough time for personal, family and societal commitments. Obstetric anaesthesia is a well-paid and sought-after speciality, and a dynamic field that demands excellent clinical and interpretative skills in a rapidly changing environment.

Effects of potential probiotic strains LBKV-3 on Immune Cells responses in Malnutrite children: a double-blind, randomized, Controlled trial.

This study investigated the phagocytic cell response in malnourished children after oral feeding of a fermented product containing clinically proven probiotic strains of Lactobacillus acidophilus, LBKV-3. The bacterial strain is used as a probiotic for humans to test its effect on immune cell activity in undernourished children below 8 years of age. To study the immune cell activity, implantation abilities of the culture in the GI tract of malnourished children, forty-five children of 6-7 and 7-8 years were randomly selected and distributed in three groups, each comprising 15 children in each of the age group. The test group of the children was receiving 100 g product volunteers/day of freshly prepared probiotic acidophilus milk containing 107 cfu/g of culture. The control group was receiving 100 g freshly prepared "dahi" containing 107 cfu/g of the LAB while the blank group of the volunteers was receiving thermal processed (85° C/30 min) buffalo milk containing 5% fat and 10% SNF at the rate of 100 ml/day/volunteer. Feeding trial was continued for 12 weeks. Blood samples were collected at W2, W4, W8, and W12. The blood serum samples were analyzed for monocytes, neutrophils, basophils, and lymphocytes by BC-3000 + Auto Hematology Analyzer. In conclusion, consumption of PAM increased the proportion of immune cells, including monocytes, neutrophils, basophils, and lymphocytes, as well as their phagocytic activity in all age groups but proportion was significant in the test group of 7-8 years. The effects were higher during W12 compared to W2, W4, and W8, which suggest regulation of the immune system.

Acute Respiratory Distress Syndrome in Pregnancy.

Acute respiratory distress syndrome (ARDS) is a clinical syndrome characterized by several clinical features and pathological responses involving the respiratory system primarily. Infections (viral), sepsis, and massive transfusion are the commonest causes of ARDS during pregnancy. The majority of them recover with noninvasive ventilatory (NIV) support. NIV is safe in pregnancy provided the center is experienced and has a protocolized patient care pathway. Parturients requiring invasive mechanical ventilation are best managed in experienced centers. PaO2/FiO2 targets are higher in parturients compared to nonpregnant patients. Permissive hypercapnia is not a safe option in pregnancy. In severe ARDS with refractory hypoxemia, prone ventilation is a safe option. However, it has to be done in experienced centers. Venovenous ECMO is a safe alternative option in pregnant women with refractory hypoxemia, and delivery has been prolonged to a safe viable age on ECMO. The decision to deliver and the mode of delivery have to be a multidisciplinary decision; primary criterion is maternal survival. Postdelivery, establishing maternal bonding while in ventilatory support facilitates early weaning and minimizes lactation failure. How to cite this article: Pandya ST, Krishna SJ. Acute Respiratory Distress Syndrome in Pregnancy. Indian J Crit Care Med 2021; 25(Suppl 3):S241-S247.

Management of pregnant laboring women during COVID-19 pandemic.

Since its first outbreak in December 2019 in Wuhan, China, coronavirus disease 2019 (COVID-19) has become a global public health threat. In the midst of this rapidly evolving pandemic condition, the unique needs of pregnant women should be kept in mind while making treatment policies and preparing response plans. Management of COVID-19 parturients requires a multidisciplinary approach consisting of a team of anesthesiologists, obstetricians, neonatologists, nursing staff, critical care experts, infectious disease, and infection control experts. Labor rooms as well as operating rooms should be in a separate wing isolated from the main wing of the hospital. In the operating room, dedicated equipment and drugs for both neuraxial labor analgesia and cesarean delivery, as well as personal protective equipment, should be readily available. The entire staff must be specifically trained in the procedures of donning, doffing, and in the standard latest guidelines for disposal of biomedical waste of such areas. All protocols for the management of both COVID-19 suspects as well as confirmed patients should be in place. Further, simulation-based rehearsal of the procedures commonly carried out in the labor room and the operation theaters should be ensured.

Comparative Evaluation of Erosive Potential of Various Frozen and Unfrozen Fruit Juices on Primary Teeth Enamel: An In Vitro Study.

BACKGROUND: Changing lifestyle pattern and food habits has a deteriorating effect on dental tissues. Dental erosion is a pathological wear of hard tissues of teeth with increased consumption of acidic and carbonated drinks. Susceptibility to erosion in primary dentition is more compared to permanent dentition due to softer and disordered crystal structure of enamel. OBJECTIVES: The main aim of the study was to determine and compare the erosive potential of different fruit juices in frozen/unfrozen forms on primary teeth by studying the calcium dissolution. MATERIALS AND METHODS: pH of four different juices (pure) - apple, orange, citrus limetta (musumbi) and grapes were determined using a digital pH meter. The titratable acidity of these in frozen and unfrozen forms were determined by adding 0.2 ml of 1M NaOH to these to raise to pH=5.5(critical pH) and pH =7(neutral pH). Forty eight caries free deciduous anterior teeth specimens were prepared to study the calcium dissolution by atomic absorption spectrophotometer. The results were analysed for statistical significance using One-way Repeated Measures ANOVA and pair wise multiple comparison with Bonferroni correction. RESULTS: Total titratable acidity and calcium dissolution were found to be significantly more in the initial thawed fruit juices. CONCLUSION: Frozen fruit juices had more buffering capacity and erosive potential than unfrozen forms. The study concluded that sucking on frozen fruit juices is more damaging to teeth than unfrozen forms because more of erosion is expected to occur in a frozen state.

Hispanic Men and Women's Knowledge, Beliefs, Perceived Susceptibility, and Barriers to Clinical Breast Examination and Mammography Practices in South Texas Colonias.

Breast cancer is the second leading cause of cancer death among women of all ethnicities. Though the disease is not a primary concern within male populations male perceptions and beliefs of breast cancer screening may contribute to a partner's or loved one's decision to engage in regular mammograms or clinical breast examinations. The current study seeks to explore a comparative analysis of breast cancer knowledge, beliefs, susceptibility, and barriers to female breast cancer and breast cancer screening among Hispanic men and women residing in the Colonias of South Texas. Using a multistage systematic sampling design, 2,812 men and women were surveyed from the two South Texas Counties; Maverick and Val Verde. Individuals between the ages of 20 and 75 (n = 2360) were included in the analysis. T-tests and linear regression models were used to examine gender differences in, knowledge, beliefs, susceptibility, and barriers to breast cancer and breast cancer screening. Significant differences were found between males and females across all measures. Regression analysis demonstrates Hispanic women hold more favorable beliefs about breast cancer and early detection, display higher perceived barriers to clinical breast examinations and mammography, and view themselves more susceptible to the development of breast cancer than their male counterparts. Results framed within a cultural context suggest outreach efforts within South Texas Colonias should consider inclusion of male family members in efforts to increase favorable views toward and engagement in regular breast cancer screening.

Obstetric ICU: Analysing and Understanding the Data is Important.

How to cite this article: Pandya ST, Mogal S, Kulkarni AP. Obstetric ICU: Analysing and Understanding the Data is Important. Indian J Crit Care Med 2019;23(5):201-202.

Association between quantitative varicella-zoster virus antibody levels and zoster reactivation in HIV-infected persons.

BACKGROUND: Varicella-zoster virus (VZV) reactivation is common but difficult to predict in HIV-infected persons. OBJECTIVE: Since qualitative VZV antibodies can determine past VZV disease or vaccination, we evaluated whether quantitative VZV antibody levels over time can predict future zoster. STUDY DESIGN: US Military HIV Natural History (NHS) participants with a zoster diagnosis at least 5 years after HIV diagnosis (n = 100) were included. Zoster-negative controls (n = 200) were matched by age, race, gender, and CD4 count at HIV diagnosis. Repository plasma specimens collected at baseline and prior to zoster diagnosis were evaluated using a quantitative anti-VZV ELISA assay. Differences in quantitative VZV levels were analyzed by Wilcoxon Mann-Whitney and Fisher's exact tests. RESULTS: Median CD4 count at HIV diagnosis was similar for cases and controls (535 [IQR 384-666] vs. 523 [IQR 377-690] cells/µL; p = 0.940), but lower for cases at zoster diagnosis (436 [IQR 277-631] vs. 527 [IQR 367-744] cells/µL; p = 0.007). Antiretroviral therapy (ART) use prior to zoster diagnosis was lower for cases (52.0%) compared to controls (64.5%; p = 0.025). Cases had similar mean VZV antibody levels prior to zoster diagnosis compared to controls [2.25 ± 0.85 vs. 2.44 ± 0.96 index value/optical density (OD) ratio; p = 0.151] with no difference in the change in antibody levels over time (0.08 ± 0.71 vs. 0.01 ± 0.94 index value/OD per year; p = 0.276). CONCLUSION: Quantitative VZV antibody levels are stable in HIV-infected persons and do not predict zoster reactivation. Low CD4 count and lack of ART use appear to be better predictors of future zoster diagnosis.

Obstetric anaesthesia practice: Dashboard as a dynamic audit tool.

Rapid advances and improved networking abilities have led to the widespread adoption of technology in healthcare, especially focused on diagnostics, documentation and evaluation, or mining of data to improve outcomes. Current technology allows for rapid and accurate decision-making in clinical care decisions for individual patients, collation and analysis at different levels for administrative and financial purposes, and the ability to visualise, analyse, and share data in real time for departmental needs. The adoption of technology may help to improve efficiency and efficacy of healthcare services. Obstetric anaesthesia is a specialised area that has to address the well-being of the pregnant woman and the unborn baby simultaneously. A shift toward caesarean sections as the major mode of childbirth has led to an increased involvement of anaesthesiologists with childbirth. Decisions are often made in high pressure, time intense situations to protect maternal and foetal health. Furthermore, labour analgesia using various neuraxial and non-neuraxial techniques is being demanded by parturients frequently, and for the materno-foetal safety, risk management is the core issue. Hence, it is essential that obstetric anaesthesia teams regularly audit their outcomes to improve services and to identify potential trouble spots earlier. It may be helpful to have audit parameters displayed as visual data, rather than complex tabular and numerical data, for ease of sharing, analysis, and redressal of problem areas. We describe the design and use of an obstetric anaesthesia dashboard that we have used in our department for the past 5 years.

Critical care in obstetrics.

Pregnancy is a normal physiologic process with the potential for pathologic states. Pregnancy has several unique characteristics including an utero-placental interface, a physiologic stress that can cause pathologic states to develop, and a maternal-foetal interface that can affect two lives simultaneously or in isolation. Critical illness in pregnant women may result from deteriorating preexisting conditions, diseases that are co-incidental to pregnancy, or pregnancy-specific conditions. Successful maternal and neonatal outcomes for parturients admitted to a maternal critical care facility are largely dependent on a multidisciplinary input to medical or surgical condition from critical care physicians, obstetric anaesthesiologists, obstetricians, obstetric physicians, foetal medicine specialists, neonatologists, and concerned specialists. Pregnant women requiring maternal critical care unit admission are relatively low in developed nations and range from 0.9% to 1%; but in our country, the admission rates of critically ill parturients range from 3% to 8%. Two-thirds of pregnant women requiring critical care are often unanticipated at the time of conception. In this review, we will look at critical illnesses in pregnant women with a specific focus on pregnancy-induced illnesses.

Ventricular Arrhythmias in the Patient with a Structurally Normal Heart.

Ventricular arrhythmias (VAs) are among the most common cardiac rhythm disturbances encountered in clinical practice. Patients presenting with frequent ventricular ectopy or sustained ventricular tachycardia represent a challenging and worrisome clinical scenario for many practitioners because of concerning symptoms, frequent associated acute hemodynamic compromise, and the adverse prognostic implications inherent to these cases. While an underlying structural or functional cardiac abnormality, metabolic derangement, or medication toxicity is often readily apparent, many patients have no obvious underlying condition, despite a comprehensive diagnostic evaluation. Such patients are diagnosed as having an idiopathic VA, which is a label with specific implications regarding arrhythmia origin, prognosis, and potential for pharmacologic and invasive management. Further, a subset of patients with otherwise benign idiopathic ventricular ectopy can present with polymorphic ventricular tachycardia and ventricular fibrillation, adding a layer of complexity to a clinical syndrome previously felt to have a benign clinical course. Thus, this review seeks to highlight the most common types of idiopathic VAs with a focus on their prognostic implications, underlying electrophysiologic mechanisms, unique electrocardiographic signatures, and considerations for invasive electrophysiologic study and catheter ablation. We further address some of the data regarding idiopathic ventricular fibrillation with respect to the heterogeneous nature of this diagnosis.

Inappropriate sinus tachycardia-symptom and heart rate reduction with ivabradine: A pooled analysis of prospective studies.

BACKGROUND: Inappropriate sinus tachycardia (IST) is debilitating despite available treatment. Off-label use of ivabradine for IST prompted this systematic analysis of existing data quality and sample size estimates for adequately powered studies. OBJECTIVE: To determine clinical efficacy of ivabradine in IST from pooled prospective studies. METHODS: Analysis included ivabradine studies for IST participants without structural heart disease and with follow-up of ≥2 weeks. Heart rate and symptom reduction with ivabradine were estimated based on results of subjective change in symptoms assessed by various data instruments used in each study. Studies were assessed for quality using validated checklists. Sample sizes were calculated based on the magnitude of symptom reduction encountered after treatment with ivabradine. RESULTS: Nine studies met criteria, culminating in 145 patients pooled. Most patients were women (≥70%). Studies were small and not adequately powered, and all reported a decrease in maximum or mean resting heart rate or both, with complete or considerable amelioration of symptoms with ivabradine. Most studies had moderate quality with excellent consistency of study quality and narrow limits of agreement between the quality checklists. Sample size estimates for adequately powered studies with various placebo effects and comparisons with ß-blockade are reported. CONCLUSIONS: Ivabradine effectively reduces heart rate and symptoms in IST, but no study was adequately powered to account for the expected placebo effect on symptoms. A multicenter, randomized, placebo-controlled, active, comparative study with a ß-blocker is needed for confirmation. This is especially relevant given the ivabradine's potential teratogenic effect, as many IST patients are females of childbearing potential.

Live versus attenuated influenza vaccine uptake and post-vaccination influenza-like illness outcomes in HIV-infected US Air Force members.

BACKGROUND: Although clinical data is limited, guidelines recommend avoiding live attenuated intranasal influenza vaccine (LAIV) in HIV-infected persons. OBJECTIVES: To evaluate non-guideline LAIV use and resulting adverse effects in an HIV-infected population. STUDY DESIGN: A retrospective analysis of influenza vaccination in US Air Force (USAF) members with HIV infection immunized between 2005 and 2015 was performed. Influenza vaccination history after HIV diagnosis was evaluated, including receipt of LAIV or inactivated influenza vaccine (IIV). The proportion with influenza-like illness (ILI) diagnoses within 30days after vaccination with IIV or LAIV was assessed by ICD-9 codes. RESULTS: 437 patients met inclusion criteria, with 121 (27.7%) receiving at least one dose of LAIV and 316 (72.3%) receiving only IIV during follow-up. The mean number of LAIV doses received was 1.5±0.89 (range, 1-4) and the majority (n=50, 82%) received their first LAIV vaccination within the first year after HIV diagnosis. Patients were predominantly males and the LAIV group had a lower mean age at HIV diagnosis (27.5±6.6) compared to the IIV group (30±7.8; p <0.001). Overall, IIV was associated with ILI diagnosis within 30days of vaccination (X2 4.58; p=0.032), with 16 cases (94.1%) occurring in those who received IIV compared to 1 case (5.9%) in those who received LAIV. CONCLUSION: Although over a quarter of USAF members received LAIV after HIV diagnosis, LAIV administration did not show an increased frequency of post-vaccine ILI diagnoses. Further education is needed to ensure that USAF members with HIV infection are vaccinated according to guideline recommendations, particularly newly diagnosed patients.

ASSIST - Patient satisfaction survey in postoperative pain management from Indian subcontinent.

INTRODUCTION: To compare pain scores at rest and ambulation and to assess patient satisfaction between the different modalities of pain management at different time points after surgery. SETTINGS AND DESIGN: The ASSIST (Patient Satisfaction Survey: Pain Management) was an investigator-initiated, prospective, multicenter survey conducted among 1046 postoperative patients from India. MATERIAL AND METHODS: Pain scores, patient's and caregiver's satisfaction toward postoperative pain treatment, and overall pain management at the hospital were captured at three different time points through a specially designed questionnaire. The survey assessed if the presence of acute pain services (APSs) leads to better pain scores and patient satisfaction scores. STATISTICAL ANALYSIS: One-way ANOVA was used to evaluate the statistical significance between different modalities of pain management, and paired t-test was used to compare pain and patient satisfaction scores between the APS and non-APS groups. RESULTS: The results indicated that about 88.4% of patients reported postoperative pain during the first 24 h after surgery. The mean pain score at rest on a scale of 1-10 was 2.3 ± 1.8 during the first 24 h after surgery and 1.1 ± 1.5 at 72 h; the patient satisfaction was 7.9/10. Significant pain relief from all pain treatment was reported by patients in the non-APS group (81.6%) compared with those in the APS (77.8%) group (P < 0.0016). CONCLUSION: This investigator-initiated survey from the Indian subcontinent demonstrates that current standards of care in postoperative pain management remain suboptimal and that APS service, wherever it exists, is yet to reach its full potential.