Journal of Nepal Medical Association

Prevalence of Cesarean Section and Its Indications in A Tertiary Care Hospital

2019-05-31T00:02:29+00:00

DOI: https://doi.org/10.31729/jnma.4282

Introduction: Cesarean section is a surgical procedure performed to deliver fetus through abdominal route. Increasing rate of cesarean section worldwide is an alarming concern for public health and obstetricians due to increase in financial burden and risk to health of the mother in comparison to vaginal delivery. The aim of the study was to find the prevalence of cesarean section and its most common indication in a tertiary care hospital.

Methods: This descriptive cross-sectional study was done in a tertiary care hospital, from July 2016 to June 2018 after taking ethical clearance from institutional review board. Convenience sampling was done to reach the sample size. Data was collected and entry was done in microsoft excel, point estimate at 95% CI was calculated along with frequency and proportion for binary data and analysis was done.

Results: Out of total deliveries conducted, 862 (36.8%) were CS deliveries, 1477 (63.1%) were vaginal deliveries, and 12 (0.51%) were instrumental deliveries. Prevalence of CS is 862 (36.8%) at 95% CI (34.82%-38.78%). Mean age±S.D of delivering mother was found to be 26.1±0.25 years. Primi cesarean section was more than repeat cesarean section. Most common indication of cesarean section was fetal distress 243 (28%) followed by previous cesarean section 165 (18%), non-progress of labour 106 (12%), oligohydramnios 59 (7%), malpresentation 59 (7%), cephalo pelvic disorders 52 (6.5%), and hypertensive disorder in pregnancy 33 (4%).

Conclusions: Prevalence of cesarean section in a tertiary care hospital is high compared to WHO data. The most common indication of cesarean section are fetal distress and previous cesarean section.

Keywords: cesarean section; fetal distress; prevalence.

Knowledge, Attitude and Practice on Antibiotics Use and its Resistance Among Medical Students in A Tertiary Care Hospital

2019-05-31T00:02:29+00:00

DOI: https://doi.org/10.31729/jnma.4224

Introduction: Antimicrobial resistance is an urgent and serious global health problem, demanding considerable attention from health care professionals worldwide. The unavoidable consequence of the widespread use of these agents has been the reason for emergence of antibiotic resistant pathogens, leading to increase in need for new drugs. This study aims to assess knowledge, attitude and practice towards antibiotics use and its resistance in undergraduate medical students.

Methods: A descriptive, cross sectional study was conducted among 228 undergraduate medical students studying in Universal College of Medical Sciences in February, 2018. Data was collected through self administered questionnaire and was entered in Statistical Package for Social Sciences 2016. Descriptive statistical analysis was carried out to find out knowledge, attitude and practice on antibiotics use and its resistance on medical students.

Results: The mean knowledge, attitude and practice score towards antibiotics use among students was 7.44±1.26, 3.35±1.12 and 5.06±1.45 respectively. Out of total students, only 39 (17.1%) had good knowledge and practice whereas 114 (50%) had good attitude towards antibiotics use. Approximately all 224 (98.2%) students were aware that antibiotics are useful for bacterial infection. Fifty two (22.8%) students said that antibiotics are safe drugs, therefore can be used commonly.

Conclusions: Although half of the students had good attitude, majority had moderate knowledge and practice towards antibiotics use. Adequate educational training should be provided to future doctors regarding proper prescribing, dispensing and usage of antibiotics.

Keywords: antibiotics; attitude; knowledge; medical students.

Prevalence of Respiratory Manifestations in Chronic Kidney Diseases; A Descriptive Cross-sectional Study in A Tertiary Care Hospital of Nepal

2019-05-31T00:02:29+00:00

DOI: https://doi.org/10.31729/jnma.4284

Introduction: Chronic kidney diseases affect patients with multiple respiratory complications by varied etiopathogenesis adversely affecting the outcome in them. The aim of the study is to find out the respiratory manifestations among patients with chronic kidney disease.

Methods: The descriptive cross-sectional study was carried out Tribhuvan University Teaching Hospital from January 2019 to March 2019 after ethical approval. One hundred and two patients with established chronic kidney diseases being treated in a tertiary hospital for a month were included for the study. Clinical evaluation and relevant investigations; chest x ray, pleural fluid analysis, sputum analysis, echocardiography, biochemical investigations and hematological investigations were done to assess the respiratory manifestations of the patients.

Results: Pulmonary edema 41 (24.84%) was the most common manifestation followed by pleural effusion 18 (10.9%). Pleural effusions were predominantly bilateral and transudative type. Pneumonia 17 (10.3%) was predominantly lobar pneumonia. Sixteen (9.7%) of the patients were screened positive for obstructive sleep apnea syndrome. Pulmonary tuberculosis was present in 9 (5.45%) patients.

Conclusions: Varieties of respiratory complications can present in varied spectrum in patients with chronic kidney diseases and this carries adverse outcome to patient management as well as affects the quality of life of the patient and their family.

Keywords: Chronic kidney diseases; obstructive sleep apnea; pulmonary edema; pulmonary tuberculosis; respiratory manifestations.

Prevalence of Ventilator Associated Pneumonia in Neonates in A Tertiary Care Hospital in Western Nepal

2019-05-31T00:02:28+00:00

DOI: https://doi.org/10.31729/jnma.4295

Introduction: Ventilator-associated pneumonia is a serious problem which needs to be addressed for a better outcome of the ventilated babies. The present study is undertaken to find out the prevalence of ventilator-associated pneumonia in neonates in a tertiary care hospital in western Nepal.
Methods: A descriptive cross-sectional study was carried out in a tertiary care hospital in the western region of Nepal from March 2016 to February 2019 after approval from the Institutional review committee. Sample size was calculated and convenience sampling was done to reach the sample size. Data were collected from hospital records and entered in Statistical Package for the Social Sciences, point estimate at 95% confidence interval was calculated along with frequency and proportion for binary data.
Results: Out of 95 patients ventilated in neonatal intensive care unit in the last 3 years, 23 (24.01%) developed ventilator-associated pneumonia. Prevalence of ventilator-associated pneumonia is 23 (24.01%) at 95% (14%-34%). Late onset ventilator associated pneumonia was seen in 15 (15.78%) while early onset ventilator associated pneumonia was seen in 8 (8.42%).
Conclusions: Prevalence of ventilator associated pneumonia in neonates in tertiary care hospital is high compared to other studies conducted in neonates.

Keywords: mechanical ventilation; neonatal intensive care unit; ventilator-associated pneumonia

Mean Nasal Index of Dental Students of A Dental College in Nepal

2019-05-31T00:02:28+00:00

DOI: https://doi.org/10.31729/jnma.4208

Introduction: Human nose is one of the important anthropometric parameters for identification of ethnicity and sex of an individual of an unknown identity. The nasal index holds a great value in anthropological studies, because it is one of the anthropometric indices acknowledged in nasal surgery as well as management. The study aims to find the mean nasal index and the nose type of dental students of Kantipur Dental College of Nepal.

Methods: This descriptive cross-sectional study was conducted among 140 dental students of age groups 17-25 years, in the Department of Anatomy, Kantipur Dental College Teaching Hospital and Research Center, Basundhara, Kathmandu. The studied population belongs to dental students of Kantipur Dental College and Research Centre. The nasal parameters including the nasal height, nasal width was measured using Digital Vernier Caliper and the nose was classified in three different types based on the value of nasal index.

Results: The mean nasal index of total population was 81.34±14.88 mm with confidence interval range of 78.85 and 83.83 mm. Mesorrhine type of nose was found to be most common among the total population. Mean nasal index in male is 84.49±12.46 mm and in female is 80.66±15.32 mm.

Conclusions: This study concludes that the mean values of nasal index of all the students falls under mesorrhine (medium) type of nose.

Keywords: Mesorrhine; Nasal height; Nasal index; Nose type; Nasal width.

Outcome of Respiratory distress in Neonates with Bubble CPAP at Neonatal Intensive Care Unit of a Tertiary Hospital

2019-05-31T00:02:28+00:00

DOI: https://doi.org/10.31729/jnma.4294

Introduction: Respiratory distress is one of the commonest problem seen in neonates during admission in Neonatal Intensive Care Unit. Hyaline Membrane disease, Meconium Aspiration Syndrome, septicemia, congenital pneumonia, Transient Tachypnea of Newborn are the major causes of respiratory distress in neonates. Bubble Continuous Positive Airway Pressure is a non-invasive respiratory support delivered to a spontaneously breathing newborn to maintain lung volume during expiration. The main objective of this study was to observe the outcome of respiratory distress in neonates with Bubble Continuous Positive Airway Pressure.

Methods: This was a descriptive cross-sectional study conducted at Kathmandu Medical College Teaching Hospital over six months (October 2018 – March 2019) period. All preterm, term and post term babies with respiratory distress were included. Ethical clearance was received from Institutional Review Committee of Kathmandu Medical College and statistical analysis was done with SPSS 19 version.

Results: Sixty three babies with respiratory distress were included in this study with 45 (71%) male predominance. The mean birth weight receiving Bubble Continuous Positive Airway Pressure was 2661.75±84 gms and gestational age was 36.67±3.4 wks. The Bubble Continuous Positive Airway Pressure was started at 8.05±2 hr of life and duration of Bubble Continuous Positive Airway Pressure required for settling respiratory distress was 95.71±3 hrs. Out of 63 babies, improvement of respiratory distress in neonates with Bubble Continuous Positive Airway Pressure was 39 (61%) with confidence interval of (38-62) whereas 24 (39%) babies required mechanical ventilation and other modalities.

Conclusions: This study concludes usefulness of Bubble Continuous Positive Airway Pressure in neonates with respiratory distress.

Keywords: bubble CPAP; respiratory distress; neonates.

Accuracy of Glucose Meter Among Adults in a Semi-urban Area in Kathmandu, Nepal

2019-05-31T00:02:28+00:00

DOI: https://doi.org/10.31729/jnma.4247

Introduction: Glucose meters are gaining popularity in monitoring of blood glucose at household levels and in health care set-ups due to their portability, affordability and convenience of use over the laboratory based reference methods. Still they are not free of limitations. Operator’s technique, extreme temperatures, humidity, patients’ medication, hematocrit values can affect the reliability of glucose meter results. Hence, the accuracy of glucose meter has been the topic of concern since years. Therefore, present study aims to evaluate the analytical and clinical accuracy of glucose meter using International Organization for Standardization 15197 guideline.

Methods: A community based descriptive cross-sectional study was conducted in Kapan, Kathmandu, Nepal in April 2018. Glucose levels were measured using glucose meter and reference laboratory method simultaneously among 203 adults ≥20 years, after an overnight fasting and two hours of ingestion of 75 grams glucose. Modified Bland-Altman plots were created by incorporating ISO 15197 guidelines to check the analytical accuracy and Park error grid was used to evaluate the clinical accuracy of the device.

Results: Modified Bland-Altman plots showed>95% of the test results were beyond the acceptable analytical criteria of ISO 15197:2003 and 2013. Park Error Grid-Analysis showed 99% of the data within zones A and B of the consensus error grid.

Conclusions: Glucose meter readings were within clinically acceptable parameters despite discrepancies on analytical merit. Possible sources of interferences must be avoided during the measurement to minimize the disparities and the values should be interpreted with caution.

Keywords: accuracy; analytical; Bland -Altman; clinical; glucose meter; Park error grid.

Nutritional Status among 6-59 Months Children in A Selected Community of A VDC

2019-05-31T00:02:28+00:00

DOI: https://doi.org/10.31729/jnma.4276

Introduction: Adequate nutrition is essential for proper growth and development of the child. We conducted a cross-sectional descriptive study to find the prevalence of nutritional status of 6–59 month old Tharu children in Duruwa VDC of Dang District. This study also deliberate the socio-economic and demographic character, maternal and child character and child feeding status of the Tharu community children.

Methods: This study is a cross-section descriptive study and was done between February and March, 2017 in Tharu community of Duruwa VDC, Dang. Total 189 children of age group 6 – 59 months were selected by using systematic random sampling technique; anthropometric measurements were performed to find the nutritional status of children. Pre-coded questionnaire was used to collect information from caretaker. WHO Anthro version 3.2.2 and SPSS version 20 were used to analyze data.

Results: Prevalence of wasting, stunting, and underweight were 25 (13.2%), 51 (27%), and 40 (21.2%) respectively. The prevalence of stunting was seen more in females than in males while underweight was higher among males, whereas wasting was very similar in both sexes.

Conclusions: The findings showed that there is still high prevalence of malnutrition in Tharu children of Duruwa VDC. So monitoring of nutrition status in Tharu children should be taken seriously and needs to be addressed.

Keywords: Dang; malnutrition; nutrition; Tharu; under nutrition.

Prevalence of Thyroid Disorder in A Primary Care District Hospital of Nepal

2019-05-31T00:02:28+00:00

DOI: https://doi.org/10.31729/jnma.4240

Introduction: Thyroid disorders are among the common endocrine disorders and may approximate diabetes in prevalence. District hospitals are in frontline to manage chronic disorders including thyroid. Primary care workforce of physicians and mid-level providers together deliver care in these hospitals. Few hospitals are equipped with tests to diagnose thyroid disorders. The objective of the study is to find the burden of thyroid disorder in a district hospital of Nepal.
Methods: This was a descriptive cross sectional study conducted in Bayalpata Hospital. One year data from July 2017 to June 2018 was collected from the electronic health record system. Data was collected from 999 patients through convenient sampling where thyroid function test was done. Subgroup analysis was done on basis of gender, symptoms at presentation and comorbidities.
Results: Prevalence of thyroid disorder in a district hospital of Nepal was 171 (17.11%) at 95% confidence interval, range occurring from 14% to 20%. Among them, 130 (76%) had hypothyroidism and 41 (24%) had hyperthyroidism. Prevalence of thyroid disorder among female was 147 (14.7%) and among male was 24 (2.4%). The most common symptom was depressed mood followed by nonspecific pain disorder, thyroid swelling, paresthesia and menstrual disturbances and common comorbidities reported were depression, diabetes, hypertension, anxiety disorder and chronic gastritis.
Conclusions: Our study showed the burden of thyroid disorders in a primary care district hospital with hypothyroidism being more common than hyperthyroidism. Thyroid disorder must be addressed on time to lower the burden. However, most of the rural population of Nepal lack in matters of lack of resources. So, it is suggested for the need to equip the health centers with thyroid tests and integrated workforce of physicians and mid-level providers in care delivery of thyroid disorders.

Keywords: district hospital; hyperthyroidism; hypothyroidism; rural; thyroid disorder.

Prevalence of Complications after Limberg Rhomboid Flap in Patients with Cutaneous Defects at A Tertiary Care Hospital

2019-05-31T00:02:28+00:00

DOI: https://doi.org/10.31729/jnma.4301

Introduction: Limberg rhomboid flap is an extremely useful and versatile technique to cover thecutaneous defects in various anatomical locations of different etiology and varied sizes. The main
aim of the study is to find the prevalence of complications after limberg rhomboid flap in patientswith cutaneous defects at a tertiary care hospital.

Methods: This descriptive cross-sectional study was conducted at a tertiary care hospital fromOctober 2015 to November 2018 after obtaining approval from the institutional review committee.
Study population is patient admitted to ward and outpatient department of surgery. Conveniencesampling was done. Data was entered and analyzed in statistical package for social sciences andpoint estimate at 95% confidence interval was calculated along with frequency and proportion forbinary data.

Results: Out of total patients, the complications were seen in total 8 (15.7%) patients. Prevalenceof complications is 8 (15.7%) at 95% confidence interval (7.85-23.56). Among which, complications
were seen in 5 (9.8%) bed sore, 2 (3.92%) in pilonidal sinus, 1 (1.96%) in traumatic ulcer and none inneoplastic lesion and types of complications seen were wound gaping in 3 (5.88%) cases, surgical siteinfection in 2 (3.92%) cases, recurrent pilonidal sinus in 1 (1.96%) case, flap necrosis in 1 (1.96%) caseand epidermolysis in 1 (1.96%) case.

Conclusions: The Limberg rhomboid flap can be used safely in patients with cutaneous defectwith minimal complications and good surgical outcome however prevalence of complications after
limberg rhomboid flap in patients with cutaneous defects at tertiary care center is high compared tothe previous studies done.

Keywords: complications; cutaneous defects; limberg rhomboid flap.

Bilateral Adductor Nerve Palsy Following Total Thyroidectomy: A Case Report

2019-05-31T00:02:28+00:00

DOI: https://doi.org/10.31729/jnma.4253

Recurrent Laryngeal Nerve palsy following thyroidectomy is usually attributed to surgery whereas sometimes the cause can be non-surgical and can result in adductor palsy. Bilateral Recurrent Laryngeal Nerve (RLN) paralysis is a rare complication of thyroidectomy. We present a 35 years female patient who developed dysphonia due to bilateral adductor RLN palsy following total thyroidectomy. The clinical findings and recovery were suggestive of a non-surgical cause for palsy in this patient. The management of these patients differs and the knowledge in this regard is very important for the surgeons. Tracheostomy is not required, and recovery of the nerve occurs in most cases in adductor palsy.

Keywords: palsy; recurrent laryngeal nerve; total thyroidectomy.

Coexistence of Gonadal Dysgenesis and Mullerian Agenesis in a Female with 46 XX Karyotype: A Case Report

2019-05-31T00:02:28+00:00

DOI: https://doi.org/10.31729/jnma.4287

Gonadal dysgenesis is a rare genetically heterogeneous disorder characterized by underdeveloped ovaries with consequent, impuberism, primary amenorrhea, and hypergonadotropic hypogonadism .Mullerian agenesis or Mayer‑Rokitansky‑Kuster‑Hauser syndrome is characterized by congenital aplasia of the uterus and the upper part (2/3) of the vagina in a woman with normal development of secondary sexual characteristics and a normal 46 XX karyotype. The association of gonadal dysgenesis and Mayer-Rokitansky-Kuster-Hauser syndrome is very rare and appears to be coincidental. We report the case of a 24-year-old woman who presented with primary amenorrhea. The endocrine study revealed hypergonadotrophic hypogonadism. The karyotype was normal, 46XX. Internal genitalia could not be identified on the pelvic ultrasound and pelvic MRI. There were no other morphological malformations.

Keywords: Gonadal dysgenesis; Mayer Rokitansky Kuster Hauser syndrome; Mullerian agenesis; primary amenorrhea; 46,XX.

Persistent Mullerian Duct Syndrome with Polysplenia and Short Pancreas: A Case Report

2019-05-31T00:02:28+00:00

DOI: https://doi.org/10.31729/jnma.4298

Persistent Mullerian duct syndrome is a rare entity and usually presents with common symptoms of undescended testis and hernia. The syndrome is caused by an insufficient amount of Mullerian inhibiting substance or due to the insensitivity of the target organ to Mullerian inhibiting substance. Polysplenia is a rare congenital disease manifested by multiple small accessory spleens. The association of these two entities is rare and has not been reported in the literature. We reported a case of a 27 years old male presented with complains of right flank pain and nausea. Ultrasound showed right ureteric calculus with hydronephrosis and elongated soft tissue mass posterior to bladder. Contrast enhanced Computed Tomography showed soft tissue suggestive of infantile uterine structure with multiple splenculi and short pancreas. He was diagnosed as Persistent Mullerian duct syndrome with unilateral cryptorchidism, polysplenia and short pancreas, coincidentally detected while evaluating for ureteric colic.

Keywords: Persistent Mullerian duct syndrome; Polysplenia; Pancreas.

Malignant Leydig Cell Tumor in Elderly Complete Androgen Insensitivity Patient: A Case Report

2019-05-31T00:02:28+00:00

DOI: https://doi.org/10.31729/jnma.4206

There are various cause of Primary amenorrhea in phenotypically females such as, complete androgen insensitivity syndrome, pure gonadal dysgenesis, 17b-hydroxysteroid dehydrogenase deficiency, or mixed gonadal dysgenesis. Primary amenorrhea in a phenotypically female is commonly encountered in Androgen insensitivity syndrome. In patients of AIS with intra-abdominal testis there is high chances of developing testicular tumour, among them Sertoli cell tumour and seminoma being the most common types. Leydig cell tumour in AIS is very rare and malignant leydig cell tumour is even further rarer. There are few case reported in the literatures of malignant leydig cell tumour with complete androgen insensitivity. Here we are reporting a case of 65 years married elderly patient with malignant leydig cell tumour with CAIS.

Keywords: Complete androgen insensitivity syndrome; Leydig cell tumour; Testicular Feminization.

Extra Hepatic Portal Vein Obstruction with Solitary Left Kidney: A Case Report

2019-05-31T00:02:27+00:00

DOI: https://doi.org/10.31729/jnma.4214

EHPVO in individual with solitary left kidney is rare occurance. Though there is no etiological association between EHPVO and solitary left kidney but the solitary left kidney decides the modality of treatment. Eighteen year lady referred to our institute with menorrhagia for 5 years and ultrasonography finding of splenomegaly and atretic right kidney. Investigations revealed Extra Hepatic Portal Vein Obstruction with multiple cavernoma formation with oesophagogastric varices with right renal agenesis. She successfully underwent splenectomy with devascularisation. Patient with EHPVO present mainly with recurrent episodes of variceal bleeding, splenomegaly and hypersplenism. Splenectomy and esophagogastric devascularisation is an effective modality of treatment for patient with EHPVO with solitary kidney.

Keywords: cavernoma; EHPVO; modified Hassab’s operation; unilateral renal agenesis.

A Simplified Understanding of the Black Swan: Anti-phospholipid Antibody Syndrome

2019-05-31T00:02:27+00:00

DOI: https://doi.org/10.31729/jnma.4226

Anti-phospholipid antibody syndrome is caused by the presence of specific antibodies against phospholipid-binding plasma proteins in serum of patient, with or without underlying autoimmune diseases, that causes prolongation of tests of coagulation. High index of clinical suspicion is required for diagnosis. Stroke or myocardial infarction in young, unprovoked recurrent deep vein thrombosis and recurrent pregnancy loss are typical scenarios where it should be suspected. Presence of non-criteria manifestations like livedoreticularis, skin ulcers, nephropathy, valvular-heart disease and thrombocytopenia adds to diagnostic clue for presence of the syndrome. Therapeutic anti-coagulation with heparin followed by warfarin is required for patients with acute thrombosis. Those with venous thrombosis are given moderate-intensity warfarin(INR 2-3), whereas those with arterial thrombosis or recurrent venous thrombosis even on warfarin are treated with high intensity warfarin (INR 3-4). Similarly, anticoagulation with heparin is advised throughout pregnancy and up to six weeks postpartum. Treatment recommendations are still not clear for asymptomatic patients and in those with non-criteria manifestations of the disease. Steroids, intravenous immunoglobulin and immunosuppressant are reported to be effective in catastrophic cases characterized by rapid small vessel thrombotic involvement of multiple organ systems. Studies are evaluating the efficacy of direct thrombin inhibitors in the management of refractory cases.

Keywords: anticoagulants; anti-phospholipid syndrome; obstetric APS; thrombotic APS.

Cancer Registration in Nepal: Current Status and Way Forward

2019-05-31T00:02:27+00:00

DOI: https://doi.org/10.31729/jnma.4192

Cancer registration is an organization for the systematic collection, storage, analysis, interpretation and reporting of data on subjects with cancer. Cancer Registry was initiated in 1995 and expanded as National Cancer Registry Program since 2003 by BP Koirala Memorial Cancer Hospital with the support of World Health Organization. NCRP currently includes 12 hospital-based registries. First time in Nepal, BPKMCH piloted population-based cancer registry in 2013, which included 15 districts covering 25.8% of total population of Nepal. NCRP is important to assure the quality of data from all the registries to ensure the availability of reliable and valid data of cancer cases. This will further help policymakers to develop prevention and control strategies of cancer. This paper reviews the current status of cancer registries in Nepal and discusses challenges and future prospective related to NCRP. National cancer registry should further include major hospitals in Nepal to give scientific information on cancer trends by community, provinces and regions and analyze on survival of cancer cases.

Keywords: cancer; national cancer registry program; Nepal.

ERRATUM of Issue 213 JNMA 2018

2019-05-31T00:02:27+00:00

DOI: https://doi.org/10.31729/jnma.4310

The online version of the “Estimation of body height from head length among dental students of a dental college”(Manandhar B, Shrestha R. Estimation of body height from head length among dental students of a dental college. J Nepal Med Assoc. 2018 Feb;56(213):861-5) has been updated according to the respective authors’ reply published in JNMA 216 Issue.
The following lines were found to be missing in methods section below sample size calculation:
The head length was measured with the help of spreading caliper from glabella to inion when the student was sitting in a chair in a relaxed state. Glabella is the most prominent point on the frontal bone above the root of the nose. Inion is the most prominent point on external occipital protuberance on head in mid-sagittal plane. Body height was measured with the help of a standard height measuring instrument as the vertical distance from vertex to the floor with the student standing barefoot, erect, on an even floor in the Frankfurt’s Horizontal Plane. Vertex is the highest point on the head in mid-sagittal plane.