Issues and Developments in Medicine and Medical Research Vol. 7

Drug delivery technology has a wide spectrum, which is continuously being upgraded at a stupendous speed. Lipid nanocarriers have emerged as a very promising, emerging and rapidly developing tool for the delivery of various drugs lacking solubility, bioavailability and stability in the recent couple of decades. Recent studies show that about 40% of newer drugs have such problems. Initially, a lipid carrier was denoted by the liposome and similar vesicular systems, but currently they are categorized as colloidal nano lipid-based carriers (CNLBC). To avoid the limitation of these CNLBCs in pH- and enzyme-dependent degradation, especially when taken orally or in physical and chemical-related stability issues, newer lipid nanocarriers such as solid lipid nanoparticles (SLN), nanostructured lipid carriers (NLCs), lipid drug conjugates (LDCs), and pharmacosomes have shown their importance at greater extent due to low toxicity, improved bioavailability, high biocompatibility, high drug-loading efficiency, protection from degradation in GIT, etc. . Nano structured lipid carriers and SLNs are non-biotoxic since they are biodegradable. Besides, they are highly stable. Their (nano-structured lipid carriers and SLNs) morphology, structural characteristics, ingredients used for preparation, techniques for their production, and characterization using various methods are discussed in this review. Also, although nano-structured lipid carriers and SLNs are based on lipids and surfactants, the effect of these two matrixes to build excipients is also discussed together with their pharmacological significance with novel theranostic approaches, stability and storage. Lipid nanocarriers can load both hydrophilic and lipophilic drug. Solubility is a rate-limiting step in the case of lipophilic drugs (BCS Class II and IV), which can be greatly modified by formulation of lipid nanocarriers. Similarly, lipidic nanocarriers can increase the permeability of most of the hydrophilic drugs (BCS I and III class) which is the rate limiting step this case. These carriers also shows good controlled and target specific drug delivery system which always attracts the attention of researchers.The current chapter aims to present a special concern related to various types of lipid nanocarriers, their detailed description on composition, different methods of preparation, influence of various types of lipids on the different properties of such carriers. It also covers the various physicochemical, formulation, pharmacokinetic, and cytotoxic aspects of such carriers. Furthermore, it includes the marketed formulations of lipid nanocarriers with their company name and trade name.

Nurse cells (NCs) have been discovered in lymphoepithelial organs. NCs show neither phagocytic ability, nor alpha-naphthyl acetate esterase (ANAE) and peroxidase cytochemical reactions. The goal was to test the hypothesis that NCs are found in tonsil epithelium (group 1), vaginal epithelium (2), and pleural fluid (3), as well as to determine the diagnostic value of palatine tonsil (PT) NCs in leukaemia. NCs were found in group 1 patients with leukaemia, group 2 patients with dysplasia and cancer, and group 3 patients with AIDS; NCs were not found in practically healthy patients (groups 1-3), cancer patients (groups 1, 3), and patients with various infections and inflammation diseases (group 1-3). NCs are atypical cells. The PT NCs can be used to detect leukaemia at an early stage.

Introduction: Oral cancer is a disease of increasing age, with an average age at diagnosis is about 60 years It is the sixth most common cancer globally with a wide geographic variation. In India, there is a trend towards increasing incidence and delayed presentation of oral cancer as approximately 50% patients present at stage III or IV where the lower socioeconomic strata of society play a vital role.

Presentation of Case: A 35 years’ male reported with the complaint of rapidly increasing ulcer in mandible. Extraoral examination revealed presence of hard nodular swelling with orocutaneous perforation while on Intraoral examination an ulcero-infiltrative, indurated lesion was present. The diagnosis was confirmed by histopathopathological examination after radiographic evaluation.

Conclusion: Despite an improvement in diagnostic and management techniques, the age-standardized mortality rates in oral cancer are constant. This article describes a case of advanced oral squamous cell carcinoma occurring at early age with an emphasis on clinical aspects of squamous cell carcinoma.

Oral cavity is the gateway of the human body, and also provides vital clues of our systemic health. Here in this COVID-19 pandemic, oral manifestations such as dysgeusia, ulcers, xerostomia are noticed and are an an important predictors of this viral disease. These are reliable clinical indicators of early clinical onset of this particular disease. This short review describes the oral manifestations of this new disease.

Pourpose: Analyze the influence of insulin resistance on the balance between carbohydrate and fat utilization at rest and in progressive intensity exercise. In many studies that measured the balance of substrate in subjects with insulin resistance, diabetes and obesity, it is a common feature the use of a fixed percentage of maximum VO₂ for intensity-control.  

Methods: Twelve sedentary male subjects were divided into two groups (>RI and <RI) according with their insulin resistance index (HOMA-IR). Using indirect calorimetry were analyzed: Carbohydrate and fat utilization at rest, the crossover point, the exercise intensity that elicits a maximal fat oxidation (Fatmax), carbohydrate and fat utilization at Fatmax. All variables were compared using the MANN-WHITNEY test.

Results: There were no significant differences between the group in Fatmax (37,35±7,99 vs. 39,81±3,84%VO₂max) and the Crossover point (40,08±7,19 vs. 40,67±5,12%VO₂máx). Also had not been observed any significant difference in the substrate balance at rest (0,095±0,009 vs. 0,069±0,028 g/min, 0,244±0,082 vs. 0,250±0,073 g/min, fat and carbohydrate, respectively) and at Fatmax (0,397±0,087 vs. 0,230±0,076 g/min, 0,689±0,229 vs. 0,867±0,222 g/min, fat and carbohydrate, respectively).

Conclusion: Insulin resistance did not influence the Crossover point and the Fatmax, as well as the substrate balance at rest and at Fatmax.

Measurement plan methodology was applied for collecting the data, as well as the identified sources of data. These are components of the approach for measurement selected for a project. The overall context of the measurement plan for the quality improvement project is to measure nurses’ challenges when conducting pain assessment in the Intensive Care Unit (ICU) with a patient who is unable to self-report. The significant part of the improvement project is a measurement plan, to address and develop a suitable way of assessing patient pain in the ICU. The recommendation is to employ the pain assessment tool to help nurses assess non-verbal patients’ pain, not to force nurses to use something they do not believe in. The tool should help the ICU nurses to assess the patients’ pain clearly and it should not increase their workload.

We report a case of surgical reconstruction of the lower lip using the Estlander technique in a 53-year-old man following a traumatic human bite. We proceeded with a reconstruction using the Estlander technique followed by a commisuroplasty to respect facial symmetry. Human bite is a challenging public health concern. It may be seen in both victims and aggressors following assault. The conventional Estlander flap is composed of skin, muscle, and mucosa with the pedicle containing labial vessels. This is the first case reported in our country to our knowledge using this technique.

Lips are structures that play an essential role in aesthetics and in different functions such as nutrition and speech.

Treatment of these defects can be complex and have significant impact on the patient’s facial function and aesthetics.

The goals of lip reconstruction include maintenance of oral competence, sufficient oral access, adequate tissue match in terms of colour and texture, proper symmetry as well as preservation of the labial commissure and sensation.

The use of flaps for the reconstruction of large defects with low risk of necrosis is possible given the abundant blood supply of the lips.

The aim of this study was to investigate the effect of different surface treatment on the osteoblastic activity of zirconia. The success of endosseous implants is directly related to the principle of osseointegration. As the surface topography of a biomaterial has a major impact on osseointegration. A total of 60 samples of Zirconia discs was fabricated and divided into three groups. Group 1[n-20]: Zirconia without treatment; Group 2 [n-20]: Zirconia treatment with sand blasting / acid etching; Group 3 [n-20]: Zirconia treatment with UV light. After, the surface treatment all the three groups were subjected to SEM scanning electron microscope to determine the surface roughness and topography. Human osteoblastic sarcoma cells were seeded on the test material at density of 1 X 104 cells / cm2 and incubated for 48 hrs at 37 + 10c under humidified atmosphere containing 5% CO . After 48 hours cell seeded test material and glass cover slips was fixed with 2.5% glutaraldehyde. SEM was done to evaluate adhesion of osteoblastic cells and colony formation on the zirconia discs and compared between the groups. There was marked osteoblast adhesion seen in the zirconia discs treated with UV light followed by etching and sand blasting, as compared to zirconia discs without surface treatment. The cell adhesion in Group I Samples were having less spread of Osteoblastic cells and had fewer osteoblastic cell colonies. Group II Samples were having more distinct spread of osteoblastic cells than group I. However, they had fewer osteoblastic cell colonies. The cell adhesion seen in group III (UV Photofunctionalisation) were showing more prominent osteoblast cells that was scattered throughout the Sample and showed better adhesion as compared to Group I and Group II. Further animal studies should be carried out. This being an invitro study cannot fully translate into in vivo conditions. In vivo conditions tissue response has to be evaluated.

The present study reporting a case of different surgical approach of Bentall procedure in pectus excavatum deformity patient. A middle-aged old man is a diagnosed case of Marfan syndrome associated with pectus excavatum presented with chest pain and dyspnoea. Diagnostic investigations like Chest X-ray, transthoracic echocardiography and Computed tomography (CT) of heart and aorta revealed severe Aortic regurgitation with dilated aortic root, sinotubular junction and ascending aorta with normal size arch of aorta and descending thoracic aorta. Surgery was planned. Heart exposure and cannulation for cardiopulmonary bypass were difficult due to Pectus excavatum. We carried out femoro-femoral bypass for ahesiolysis and Bentall procedure without much difficulties. Postoperative stay of the patient was uneventful and followed up in regular interval. Marfan syndrome is associated with many disorders that affect different systems of the body, these patients always require an individual approach.

Aim: This case study discusses a unique custom-made attachment on the abutment teeth that was used to improve the retention and stability of a removable partial denture. It also sheds light on a low-cost method for changing the abutment teeth with the help of crowns and custom-made attachments.

Background: Achieving retention in Kennedy's class I bilateral edentulism usually has an impact on the periodontal health of the abutment teeth, and eventually the retention is compromised. The patient's masticatory efficiency is also impacted by distal extension edentulism. The rehabilitation of a patient with the long span Kennedy's class I condition is complicated by the lack of a sufficient number of abutments to support the prosthesis. For the same reason, conventional removable prostheses with clasps and cantilever fixed partial prostheses are not recommended in this situation.

Case Description: A case involving the Kennedy class 1 modification 1 partially edentulous arch with missing 1st and 2nd molars, as well as central incisors, was rehabilitated with a low-cost custom attachment that used a die-pin and sleeve to provide a fixed prosthesis on abutment teeth and a removable prosthesis with missing teeth.

Conclusion: This procedure has the following advantages: better retention than traditional RPDs, protection of abutment health by repairing it with a crown, ease of placement and removal, and low cost.

Clinical Significance: The entire technique demands less skill compared to semi-precision and precision attachments.

Chronic Kidney Disease (CKD) patients have very poor appetite and added to this they are on polypharmacy, many of which causes nausea and gastroparesis. Majority of patients have diabetes mellitus and hypertension hence cannot consume much salt and sugar. Hence there is poor appeal for food palatability. To improve their intake of nutritious foods it becomes mandatory to venture on good palatable foods with appropriate nutrients bearing in mind renal dietary regimen. This includes limiting potassium, salt content and fluid in foods. Our effort of present publication is on this line. Five renal food products were prepared and each was subjected to sensory evaluation among thirty subjects of patient group and controls. There was satisfactory acceptance for all the renal foods showing its palatability.

Introduction: It is generally accepted that laminoplasty is a safe and reliable surgical treatment for cervical spine myelopathy (CSM) due to spinal canal stenosis. There are multiple techniques of laminoplasty for spinal cord decompression and most of them require expensive instruments to stabilize the laminae. From 2005 to 2015, we applied the modified Z-plasty (Sakou's technique) for CSM patients in an attempt to reduce the cost of treatment.

Aim: This present study discuss about Modified Z-Plasty for Cervical Spine Myelopathy. The Z- laminoplasty was the technique of choice of our department of spinal surgery for multilevel cervical stenosis as it did not require any expensive devices to secure the laminae and provided good outcome.

Materials and Methods: This is a retrospective study. CSM patients treated by modified Z-plasty technique were selected. We applied the Sakou’s technique, according to which the laminae will be opened in different directions alternatively. We use the JOA score and recovery rate of Hirabayashi to assess the neurological recovery and the Neck Disability Index (NDI) for the cervical functional outcome.

Results: There were 42 patients with the mean follow- up duration of 10 years (5-15 years), male: female ratio of 3:1 and mean age of 61. The mean operating time and blood loss per lamina were 40 minutes and 45 ml, respectively. The canal expanding index was 4.2 mm (3-5 mm). The mean pre- and postoperative JOA score were 11.1 and 14.7, respectively (p<0.05). For the axial pain, the mean NDI was 18 point with 88% of cases having as good and very good cervical function. For complications, there were 3 cases of C5 palsy with full recovery after one year.

Conclusion: Being considered as an old-fashioned surgery, the modified Z-plasty can still provide good clinical and radiological outcomes to cervical myelopathic patients. The absence of hardware such as titanium plates or hydroxyapatite spacers reduces the risk of infection and the cost of treatment. Considering the risk-benefit and cost-benefit ratio, this operation is suitable for low-income patients in developing countries.

The current study evaluates the potential of spunbond, SMS, and spunlaced nonwoven fabrics of different fabric weights for surgical gowns characterized for liquid barrier properties, antimicrobial properties, blood repellency, air permeability, and stiffness. Surgical gowns are commonly used in healthcare facilities as part of surgical staff protective equipment to reduce the transmission of microorganisms to surgical patients as well as surgical staff exposure to infectious agents like HIV, hepatitis B, and hepatitis C. Polypropylene spunbond, spunlace, and spunbond/melt blown/spunbond fabrics with different basis weight i.e. 35 g/m² and 50 g/m² are used to estimate the barrier properties against microorganisms and liquid or body fluids. The selected fabric samples are analyzed for Liquid barrier properties by the hydrostatic pressure test, water impact penetration, and resistance to synthetic blood. The antibacterial activity of the fabric samples is analyzed with Staphylococcus aureus. Air permeability thickness and stiffness force are tested for evaluation of comfort properties. The results show that SMS fabric samples of 35 g/m² and 50g/m² weight offer sufficient liquid barrier properties for level II protections as per AAMI barrier protection classification, whereas the other two fabric samples offer only level I protection. SMS fabrics are not very comfortable as compared to spunbond and spunlaced fabrics due to their higher stiffness and lower air permeability values, but the highest permeability and lowest stiffness force were offered by Spunlace fabric. Further, it was noticed that as the weight of fabric increases, the stiffness force increases and air permeability decreases. All the fabrics did not show any bacterial resistance or blood repellency.

Background: The Anterior Cruciate Ligament (ACL) injury is uncommon, but constitutes an important percentage of the lesions requiring more than 8 weeks of recovery in sports. Most ACL injuries do not require external contact and are associated with biomechanical risk factors that stress this ligament ACL: like an increase in knee valgus an- gle (KV) and hip flexion (HF) and a decreased in knee flexion (KF). The ACL requires muscle cooperation to resist the load; however, when there is fatigue, the protective capacity of the musculature would decrease.

Objectives: The objective of the study is to analyze the angular behavior before and after a physical load for HF in children of 14-15 years old

Hypothesis: The physical load applied in a single training session is enough to change some biomechanical risk factors of ACL injury.

Study Design: Experimental study.

Level of Evidence: 2b.

Methods: The sample consisted of 50 students from different soccer schools between 14-15 years old. We analyzed the hip angular behavior of hip flexion before and after a training session. The angles where obtained from inertioal sensor while the students performed a Drop Jump test from a 30 centimeters drawer.

Results: Statistically significant differences were found in the differences between pre physical load HF / post-load HF (p = 0.00053), right pre physical load HF / right post- load HF (p = 0.0086) and left post- load (p = 0.0248206).

Conclusions: It was concluded that the angular behavior of HF increases significantly in both post-training limbs, after performing a physical load.

Clinical Relevance: This study analyzed the importance of using prevention injury programs since early stages, and give importance to the eccentric role of hamstring, gluteus and core exercises.

Introduction: Disordered phosphate homeostasis with elevated circulating levels of fibroblast growth factor 23 (FGF-23) is an early complication of CKD leading to different types of bone diseases. Treatment strategies are designed to keep calcium, phosphate, parathyroid hormone (PTH) and vitamin D within defined ranges for patients with these bone diseases. Presently, FGF 23 is not included into standard treatment protocols for management of bone diseases in CKD.

Objective: Primary Objective: The primary objective of the study was to compare and correlate FGF 23 levels in patients with CKD with calcium, phosphorus, vitamin D and parathyroid hormone levels.

Secondary Objectives: 1) To determine association between haemoglobin level and corresponding FGF 23 level in patients with CKD in different stages.

2) To study variations in FGF 23 levels in high and low turnover bone disease.

Methods: We examined the working hypothesis that FGF-23 is an indicator of CKD progression and related bone diseases.  We examined if its appearance is earlier than other parameters like calcium, phosphate, PTH and vitamin D in CKD progression. To understand ‘off target’ effects of FGF-23 we included the presence of anaemia as an additional parameter. We attempted to study variations in FGF 23 level in high and low turnover bone diseases and effects of phosphate binders on FGF 23 in these two types of bone diseases.

It was an observational open label prospective study conducted in 2015-16 at Care Hospitals, Hyderabad, India. It included all adult patients with CKD selected sequentially.

Results: A Kruskal Wallis test was run on 64 samples showed statistically no  significant difference of FGF23 between different stages of CKD.  There was a statistically significant difference in haemoglobin levels among different stages of CKD. FGF 23 levels were higher in patients with high turnover type of bone disorder but Wilcoxon Mann Whitney test results indicated no statistical significance. The chi-square test results indicated that there was a statistically significant effect of phosphate binders on FGF 23 levels.

Conclusions: FGF-23 and haemoglobin correlated inversely in a subgroup analysis of high and low turnover bone diseases. FGF 23 was lower in low turnover disease and higher in high turnover bone disease. Although this correlation was statistically insignificant, FGF 23 may differentiate high and low turnover bone disease. Serum intact FGF-23 levels did not correlate statistically with progression of CKD. The effect of phosphate binders on lowering FGF-23 levels was statistically significant.

Smoking with prolonged exposure to low oxygen levels is a common risk factor for cardiovascular diseases and other health problems. Long term exposure to low oxygen levels leads to increase erythropoietin production that in turn increases red blood cell mass and decreases plasma volume which can elevate blood viscosity, impairing blood flow, making individuals susceptible to vaso-occlusive events. Smoking that results in secondary polycythemia and erythrocytosis can cause additional harm in smokers. This mini-review article attempts to understand the strong association between smoking and erythrocythemia as a cause of cardiovascular disease. Polycythemia in smokers can be defined by an expansion of red cell mass with elevated haemoglobin and hematocrit as a physiologic response to increased erythropoietin production secondary to generalized tissue hypoxia. Hypoxia in smokers’ polycythemia is present with normal or falsely elevated oxygen saturation value. In addition, this article focuses on the importance of being aware of cardiovascular risk in patients with polycythemia due to chronic smoking exposure.

Aspirin, acetyl salicylic acid or 2-acetoxybenzoic acid, has the carboxylic acid functional group hence easier to quantify using a strong alkali like NaOH. Overdoes of aspirin can have serious consequences, resulting in significant morbidity and death. In most analgesic drug formulations in tablets form, aspirin is generally bind or compounded with other excipients or substituents which are acidic in nature and has acidic groups thus reacts easily with NaOH, hence making sodium hydroxide not a suitable reagent for quantifying aspirin in multicomponent aspirin tablet formulation. Six different tablets from reputable drug manufacturing company containing aspirin as an active substance were taken. Methods using sodium hydroxide as the main reagent in quantification involves a lot of stoichiometric mathematical manipulations as in case of titrimetric method while UV-VIS spectroscopy via multivariate calibration gave values at lower limit or outside the lower limits of US & BP pharmacopeia with respect to label claims, while the HPLC gave very good resolution and precise results within the pharmacopeia limits.

The present study provides an overview of Allergic Rhinitis and its management. It is very useful for students of Rhinology and clinicians managing this disease. It introduces them to a systematic approach of assessing allergic rhinitis patients which is very commonly found in most populations and causes considerably morbidity. Allergy per se is a very difficult subject to master and it is with great perseverance one can treat patients suffering from this condition. The cornerstone of managing a patient of allergic rhinitis is first and foremost obtaining a good history. This is to be followed by a thorough examination and investigations. The general practitioner is the first expert to be involved in management of allergic rhinitis patient followed by specialists in particular otorhinolaryngologists, and finally by allied healthcare personnel. Inflammation of nose and paranasal sinuses are characterized by two or more symptoms-namely, either nasal blockage / obstruction / congestion or nasal discharge. Associated symptoms include facial pain / pressure and either reduction or loss of smell. Certain diagnostic endoscopic signs of nasal polyps and or mucopurulent discharge and or mucosal oedema in the middle meatus and or CT changes of mucosa within the ostoemeatal complex, and or sinuses are seen. Definitions, aetiologies, clinical presentations, diagnosis / prognosis and management of allergic rhinitis is dealt with. Common allergens causing the disease are mentioned, pathophysiology and classification of allergic rhinitis is discussed in detail. Different types of allergen testing are highlighted along with their specific role and uniqueness. Principles of immunotherapy in treatment of allergic rhinitis are discussed here. Health effects of allergic rhinitis along with its impact on physical quality of life is mentioned. The main goal of this presentation is to enhance diagnosis accuracy by encouraging appropriate use of ancillary tests such as nasoendoscopy, allergy testing, computed tomography, and other similar procedures, as well as reducing unnecessary antibiotic use. The severity and duration of allergic rhinitis determine the treatment method. Allergen avoidance, medication, allergen immunotherapy, and surgery with a limited function are included.

The posterior condylar canal enters the skull at the base, just behind the occipital condyles. The largest emissary foramen of the posterior cranial fossa is the posterior condylar canal. The posterior condylar vein leaves the skull via the posterior condylar (or condyloid) canal, which connects the jugular foramen to the condylar fossa. The purpose of this study was to identify the normal anatomic pattern and variations of the posterior condylar canal.The objectives of the present study a) To note the presence of bilateral or unilateral and absence of posterior condylar canal (foramen).

Materials and Methods: The current study used 50 dry adult human skulls of unknown sex obtained from the department of anatomy at Mysore Medical College and Research Institute in Mysore. Skulls were examined directly for the presence or absence of a posterior condylar canal, both bilaterally and unilaterally. We found bilateral posterior condylar canal (foramina) in 18 of the 50 human dry skulls, unilateral (right) in 10 skulls, and unilateral (left) in 12 skulls. In 10 skulls, there is no posterior condylar canal (foramina).

Conclusions: Anatomical variations of the posterior condylar canal are important for Neurosurgeons and ENT Surgeons because it provides them with a comprehensive understanding of how to operate in the vicinity of occipital condylar regions.

A-91-year-old man had severe Covid-19 infection as he had bilateral severe pneumonia with SaO2 85% on air. He was treated with antibiotics, oxygen, dexamethasone and convalescent plasma therapy. Following recovery from respiratory failure, on day 28 symptom onset, he had loose motion and abdominal distension without abdominal pain. Then, he suddenly developed septic shock and features of peritonism. CT abdomen revealed pneumoperitoneum. After resuscitation with fluids, inotropes and antibiotics, emergency laparotomy was done. An area of perforation at colon with mucosal hemorrhage was seen. Right hemicolectomy was done. Histology showed mucosal oedema, infiltration with inflammatory cells mainly polymorphs and lymphocytes, congested vessels with areas of hemorrhage in the mucosa. Post-operative period was critical; septic shock required two inotropes, blood transfusion and fluids. It was complicated by ARDS and multiorgan failure.

Aim: To evaluate the accuracy of the Root ZX and Elements-Diagnostic electronic apex locators when compared to radiographs for locating the canal terminus or minor foramen.

Methodology: The canal terminus of 482 canals in 160 maxillary and mandibular teeth was located in vivo with both locators and radiographically. After extraction the actual location of the minor foramen was determined visually and with magnification. A paired samples t test, X2 test and a repeated measure ANOVA at the 0.05 level of significance were used to determine differences between the groups.

Results: The Root ZX located the minor foramen correctly 68% of the time in anterior and premolar teeth, and 58% of the time in molar teeth. The Elements-Diagnostic located the minor foramen correctly 58% of the time in anterior and premolar teeth and 49% of the time in molar teeth. Radiographs located the minor foramen correctly 20% of the time in anterior and premolar teeth and 11% of the time in molar teeth. There was no statistically significant difference between the two locators but there was a significant difference between them and radiographs. For all teeth, the measurements made by the apex locators were within ±0.5 mm of the minor foramen 100% of the time, whereas for the radiographs, the measurements were within this range only 15% of the time.

This difference was significant (p= 0.05).

Conclusion: Measuring the location of the minor foramen using the two apex locators was more accurate than radiographs and would reduce the risk of instrumenting and filling beyond the apical foramen.

The present study aims to highlight the problems faced by orthopedic surgeons while treating geriatric orthopedic patients in rural set up and amicable solutions which can improve status of managing the osteoporosis and geriatric orthopedic problems in rural India. Osteoporosis or fragility is a big issue and implant holding and other issues related with osteoporosis are more prominent in rural area. Osteoporosis and osteoarthritis go hand in hand and we have to treat both ailments simultaneously. Comprehensive treatment approach is must. Health education and public awareness is must. Prevention is always better than cure. Better patient care can be achieved through education and research.  Social and economical issues in rural area should be taken care of properly to manage osteoporosis in rural area.