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Calcium-channel blocker overdose can result in profound vasoplegia and cardiogenic shock, which can quickly spiral into multi-organ failure and death. In this case report, we discuss two separate cases of massive amlodipine overdose with polydrug intoxication (Patient A: amlodipine and quetiapine; Patient B: amlodipine, fluoxetine and zopiclone), both of which were complicated by life-threatening vasoplegic shock refractory to supportive therapy (endotracheal intubation, fluid resuscitation, activated charcoal, vasopressors and inotropes), multimodal antidotes (calcium and hyper-insulinemic euglycemic therapy) and even second-line treatment (methylene blue and therapeutic plasma exchange). Despite exhausting all therapeutic options, resuscitation remained futile with no clinical response elicited until veno-arterial extracorporeal membrane oxygenation (ECMO) salvage therapy was initiated in both cases as a bridge-to-recovery. Albumin dialysis was also commenced to further enhance elimination of amlodipine given its high plasma protein-binding properties. Both patients improved drastically once perfusion to vital organs was maintained by ECMO and eventually survived with good neurological outcomes and preserved cardiac contractility on discharge. This case report supports the growing evidence that although ECMO support represents a potentially life-saving salvage therapy for refractory poisoning-induced shock, escalation to ECMO must be considered and instituted early before irreversible multi-organ failure sets in to ensure good clinical outcomes. [ABSTRACT FROM AUTHOR]

Iatrogenic injury and/or damage to the parotid salivary gland during transparotid approach for open reduction and internal fixation of mandibular condyle fracture is a rare event. Accumulation of saliva in the gland leads to formation of a sialocele. Huge sialocele often seeks drain through the most dependent area through an extraoral wound, whereas in the absence of extraoral fistula, saliva can be redirected intraorally using a stent. A case of management of sialocele caused by damage to glandular elements during a transparotid approach for a subcondylar fracture reduction is reported. The various conservative methods and surgical management for this condition are discussed. [ABSTRACT FROM AUTHOR]

Medicinal leeches are extremely useful and safe in the salvage of venous outflow compromised tissue, particularly in digit replants and various forms of flaps. Although it is unusual for a partial soft tissue avulsion of the face to require medicinal leech therapy, situations may occur in which there is adequate arterial inflow but inadequate venous outflow. In such cases, medicinal leeches may play a very important role in salvaging the soft tissue segment. We report a case of a 34-year-old gentleman who showed signs of venous congestion following primary management for a traumatic nasal flap. Successful salvage of venous congestion was done using medicinal leech therapy, once daily, for 5 days. His recovery deemed satisfactory and uncomplicated. Medicinal leeches are well-known in the treatment of venous congestion or complete venous outflow obstruction in larger pedicled flaps and microvascular transfers. In trauma, it is well established that medicinal leeches are invaluable in treating venous congestion in digit replants and replantation of totally avulsed external ear segments. A limited number of other reports have demonstrated the use of medicinal leeches for salvage of other partially avulsed facial structures. Medicinal leeches have a significant role in the management of traumatic and microvascular flaps, the oral and maxillofacial surgeon should weigh the benefits of such treatment before instituting other expensive or complex treatment modalities. [ABSTRACT FROM AUTHOR]

The article discusses a study that analyzes the emission of aerosol in Electrical Discharge Machining (EDM), a commonly used non traditional manufacturing process. The researchers evaluate the pulse duration, peak current, dielectric flushing pressure and the level of dielectric as varying process parameters of aerosol emission. The study reveals that when the peak current increases, aerosol concentration also increases and decreased with increase in the flushing future.

In view of the ongoing environmental and ecological changes in the Western Ghats, it is important to understand the environmental parameters pertaining to the sustenance of the region. Rainfall is one such parameter governing the hydrological processes crucial to agriculture planning, afforestation and eco-system management. Therefore, it is essential to understand rainfall distribution and its variation in relevance to such activities. The present study is an attempt to gain in-depth understanding in this direction. The study area comprises of one coastal district and its adjoining areas in Karnataka State. Mean annual rainfall data of 93 rain gauge stations distributed over the study area for a period of 10-50 years are used for the study. In order to assess the variation of rainfall across the ghats, several bands were constructed parallel to the latitudes to facilitate the analysis. The statistical analyses conducted included cluster analysis and analysis of variance. The study revealed that there exist three distinct zones of rainfall regimes in the study area, namely, Coastal zone, Transition zone and Malanad zone. It is observed that, the maximum rainfall occurs on the windward side ahead of the geographical peak. Further, mean monthly rainfall distribution over the zones has been depicted to enable agricultural planning in the study area. [ABSTRACT FROM AUTHOR]

It is time to look beyond lifestyle changes, control of glucose, lipids and blood pressure for cardiovascular disease (CVD) risk reduction. Should we be looking at insulin levels? Accumulation of insulin or hyperinsulinemia is largely an attempt by the body to overcome the state of reduced insulin sensitivity in the tissues involved in glucose homeostasis. Though glucose homeostasis may be achieved by pharmacological measures, it does not seem to translate into significant CVD event reduction unless there is concomitant reduction in the raised insulin levels due to insulin resistance (IR). Does IR affect all aspects of insulin action or does it differentially affect the downstream signal pathways? There is a new concept supported by experimental studies of 'selective IR.' These experiments looked at impaired progression of signals through PI3 kinase pathway and possible greater progression through the MAP kinase pathway, eliciting greater response of the downstream targets from the compensatory hyperinsulinemia. Unimpaired MAP kinase pathway may contribute to the pro-atherogenic milieu in metabolic syndrome (MetS). Targeting insulin levels by drug therapy is needed as lifestyle measures are not sustainable in the long term. [ABSTRACT FROM AUTHOR]

A letter to the editor is presented in response to the article "Mosaic Pancreas or Type 3 Diabetes" and "Type 2 Diabetes Can Be Multigenerational," published in the previous issue.