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Background: Although the removal of impacted mandibular third molars is a common minor oral surgical procedure, the extraction of these teeth can present with certain post-operative complications. Koerner KR proposed a Diffi culty Index Scale for removal of these teeth on the basis of local anatomy and radiographs, which were helpful in predicting the diffi culty that would be encountered intra-operatively, as well as the post-operative complications. Objective: To study the different post-operative complications in the removal of impacted mandibular third molars calculating their diffi culty index value. Method: A total of 119 patients, 79 females and 40 males who underwent extraction of their impacted third molars were selected over a one year period. Data were collected prospectively, according to the angulation, depth and position of the impacted mandibular third molars and their diffi culty index calculated. This was further correlated with the postoperative complications encountered. Results: Mesio-angular impaction (43.7%), with level A (66.4%) and Class I (70.6%) impaction were the major type of impaction seen. The diffi culty index showed that majority were in the moderately diffi cult category (51.2%), with swelling and trismus seen to increase as the diffi culty index value increased. Females were affected more than males, with swelling (Odds ratio 2.206) and trismus (Odds ratio 2.570) seen to be signifi cantly more. Conclusion: Surgical removal of impacted mandibular third molars causes post-operative complications and special care is required in their removal, especially in females. The Diffi culty Index, as described by Koerner KR can be used as a tool for predicting the frequency of the post-operative complications, especially swelling and trismus.

A 31-year-old male with no past history of any significant medical illness manifested with acute onset of behavioural problems of seven-eight days duration in form of increased psychomotor activity, elated mood, verbosity, distractibility, enhanced self esteem, hyper-religiosity, delusion of grandiosity, impaired biodrives (sleep, appetite and libido) in absence of any perceptual disturbance and with intact sensorium. There was no history of fever, altered sensorium, neurological deficit and significant weight loss prior to onset of behavioural abnormalities. There were no developmental issues. Physical examination revealed pulse 82/min, BP 130/82 mm of Hg, afebrile, respiratory rate was 16/min, no digital tremors or hyperhydrosis. Lab investigations including heamogram, LFT, urea, creatinine, blood sugar, lipid profile, serum electrolyte, X-ray chest, CT Scan Brain, T3, T4, and TSH was within normal limits and HIV status was negative. He was diagnosed as a case of mania with psychotic symptoms as per International Classification of Diseases 10 (ICD10) [1] and started on mood-stabilizer tab divalproex sodium 500 mg BD and olanzapine 5 mg BD. Patient started showing improvement. By 10 th day his symptoms remitted to about 40% however his hyper-religiosity, self esteem and grandiose manners though less severe persisted, however on 13 th day patient complained of headache right hemi-cranium lasting for half hour to one hour accompanied by nausea and vomiting. His pulse, BP and temp were normal. MRI brain and fundoscopy revealed no abnormality. A neurophysician referral resulted in prescription of tab topiamate 25 mg BD in view of vascular headache and the same evening (15 th day of admission) after receiving tab topiramate patient developed disorientation, confusion, unsteadiness of gait, irrelevant talks and agitation which continued for next three-five days. His topiramate was stopped immediately. His MMSE score was 13/30. Subsequently divalproex sodium was increased to 1500 mg along with 15 mg of olanzapine by 22 nd day. EEG revealed normal bilateral symmetrical 9-12 Hz posteriorly dominant alfa rhythms. Patient did not show any improvement and continued to remain puzzled, dazed, confused and disoriented during day time with irrelevant talk and exhibited more hyperactivity towards evening with altered sleep-Wake schedule. His physical examination revealed pulse 88/min, BP 136/88 mm of Hg, respiratory rate 18/ min. There were no menningeal, cerebellar or extra pyramidal signs. keywords: Bipolar disorder, Encephalopathy, Non hepatic hyperammonemia, Valproic acidHis neurological examination was non contributory. His repeat liver function, electrolyte, urea, creatinine and CPK levels were within normal range. A pre-anesthetic check up was done and after taking appropriate consent of patient and relatives, he was taken up for electroconvulsive therapy (ECT) on 29 th day suspecting it to be a case of Delirious mania. ECT was planned twice a week. Before starting ECT dose of divalproex sodium was reduced to 250 mg BD t...

Background: In order to promote rational drug use in developing countries, assessment of drug use pattern using the World Health Organization drug use indicators is important. The aim of this study was to assess the drug prescription patterns at Kathmandu Medical College Teaching Hospital, using some of the World Health Organization core drug use indicators.Methods: A prospective cross-sectional study was carried out in order to determine current prescribing trends at Kathmandu Medical College Teaching Hospital. A total of 605 prescriptions were collected and analyzed in the study.Results: The average number of drugs per prescription was 5.85 considering the total amount of prescriptions. Furthermore, assuming each prescription as an individual patient, 64.1% of patients received antibiotics, and 71% of patients received injectable form of drugs. Among antibiotics the most common antibiotics prescribed were Ceftriaxone, Amoxicillin/Cloxacillin, Azithromycin, Cefixime, and Cloxacillin. Only 16.94% of the medicines were prescribed in generic names with the rest 83.06% of the medicines being prescribed in brand names and 47.55% of medicines prescribed were from the National List of Essential Medicines-Nepal.Conclusions: The current study revealed that polypharmacy and prescription writing using brand names were common. Prescriptions writing in generic name needs to be promoted and encouraged. There appears to be a crucial need for the development of prescribing guidelines when it comes to antibiotics. Keywords: Drug prescription; drug utilization; prescribing practices; rational drug use; WHO prescribing indicators.