Soonchunhyang University Bucheon Hospital Research Articles

뚜렛 장애 아동 청소년의 기능장애 및 실행기능 결함 : 주의력결핍 과잉행동장애 아동 청소년과 정상 대조군과의 비교

Objectives:The aim of this study was to determine whether children with Tourette disorder (TD) have functional impairment and executive dysfunction in comparison to children with attention-deficit hyperactivity disorder (ADHD) and non-affected controls. Methods:From January 2006 to December 2013, 45 children and adolescents with TD and 50 children and adolescents with ADHD diagnosed at the Soonchunhyang University Bucheon Hospital and 50 non-affected controls were enrolled in this study. Functional impairment of the subjects was assessed using the Child and Adolescents Functioning Impairment Scale (CAFIS), parent and teacher versions. In addition, neuropsychological tests including Stroop color-word Test, Finger windows Test (FWT), and Digit span were administered. Outcomes were compared across the TD, ADHD, and non-affected controls. Results:No difference in CAFIS-parent and CAFIS-teacher results was observed between children with TD and non-affected controls, whereas, children with ADHD showed more impairments relative to non-affected controls in the CAFIS-parent. According to the Stroop color-word Test, FWT, and Digit span, executive function in children with TD did not differ from non-affected controls. Children with ADHD had poorer performance in measures of the Stroop color-word Test compared to children with TD. Conclusion:Children and adolescents with TD but not ADHD were not significantly different from non-affected controls on most measures of functional impairment and executive function. These findings suggest that an education program and intervention for children with TD would be important to reducing the stigma of TD.

Comparison of Quality of Life and Nutritional Status in Gastric Cancer Patients Undergoing Gastrectomies.

The aim of this study was to compare the quality of life (QoL) depending on the postoperative survival period or nutritional status in gastric cancer patients. Surviving gastric cancer patients (n = 222) after the gastrectomy were included in the study at Soonchunhyang University Bucheon Hospital from April 2010 to August 2012. The Korean versions of the European Organization for Research and Treatment of Cancer (EORTC) Quality of Life Questionnaire Core 30 (QLQ-C30) and a gastric cancer-specific module, the EORTC QLQ-STO22, were used to assess the QoL. The postoperative survival period of the patients fell into two groups; the less-than-1-year group or the more-than-1-year group, and the nutritional status of the patients fell into three groups by a score of patient generated-subjective global assessment (SGA)-A, B, and C. As a result, the rate of malnutrition was 34.5% in the less-than-1-year group and 19.8% in the more-than-1-year group, respectively. Score for the fatigue (p = 0.006), loss of appetite (p = 0.002), reflux (p = 0.027) and body image (p = 0.004) in which the QoL was significantly lower in the less-than-1-year group than in the more-than-1-year group. The score of QoL according to the nutritional status of all subjects, overall health status (p = 0.043), physical functioning (p = 0.016), fatigue (p = 0.006), pain (p = 0.028), loss of appetite (p = 0.017), reflux (p = 0.003), eating restriction (p = 0.002), anxiety (p = 0.010), and body image (p = 0.001) was significantly lower in the SGA-C group than in other SGA groups. These results suggest that the nutritional status of the gastrectomy patients with stomach cancer may impact on their QoL. It is necessary to to develop nutritional intervention to improve QoL in gastric cancer patients with postoperative malnutrition.

Quantitative CT Assessment in Chronic Obstructive Pulmonary Disease Patients: Comparison of the Patients with and without Consistent Clinical Symptoms and Pulmonary Function Results

Boda Nam, MD, Jung Hwa Hwang, MD*, Young Mok Lee, MD, Jai Soung Park, MD, Sung Shick Jou, MD, Youngbae Kim, MD 1Department of Radiology, Soonchunhyang University Hospital, Seoul, Korea 2Bangbae GF Allergy Clinic, Seoul, Korea 3Department of Radiology, Soonchunhyang University Bucheon Hospital, Bucheon, Korea 4Department of Radiology, Soonchunhyang University Cheonan Hospital, Cheonan, Korea 5Department of Preventive Medicine, Soonchunhyang University College of Medicine, Cheonan, Korea

Long-term efficacy of primary intraoperative recurrent laryngeal nerve reinnervation in the management of thyroidectomy-related unilateral vocal fold paralysis

Conclusion: Primary intraoperative recurrent laryngeal nerve (RLN) reinnervation techniques demonstrated significant voice improvement at 24 months postoperatively and could be an effective alternative treatment for thyroidectomy-related permanent unilateral vocal fold paralysis (VFP). Objectives: To assess the long-term efficacy of intraoperative RLN reinnervation techniques in the management of thyroidectomy-related unilateral VFP. Methods: A prospective study was conducted from January 2008 to June 2012 at Soonchunhyang University Bucheon Hospital. Nineteen patients who underwent RLN reinnervation with either direct reinnervation (neurorrhaphy) or ansa cervicalis to RLN (ansa-RLN) anastomosis and completed subjective and objective voice measurement over a 1-year follow-up period were included in this study. Results: The causes of VFP were cancer involving the RLN (68.4%, 13/19) and iatrogenic nerve transection (31.5%, 6/19). Reinnervation techniques were direct neurorrhaphy (63.2%, 12/19) and ansa-RLN anastomosis (36.8%, 7/19). Subjective parameters such as the Voice Handicap Index (VHI), posterior glottic closure, and mucosal wave demonstrated significant improvement 6 months postoperatively, and the majority of parameters remained stable up to 24 months (p < 0.05). Objective parameters, such as maximum phonation time (MPT), jitter, shimmer, and the harmonics-to-noise ration (HNR), demonstrated significant improvement at 12 months and most remained stable at 24 months (p < 0.05).

FREQUENCIES OF VARIOUS CLINICAL SYMPTOMS OR SIGNS OF DEMENTIA WITH LEWY BODIES (DLB)

SYMPTOMS OR SIGNS OF DEMENTIAWITH LEWY BODIES (DLB) Bo Kyung Sohn, Min Soo Byun, Young Min Choe, Jee Wook Kim, Shin GyeomKim, Jong InnWoo, Dong Young Lee, SMG-SNUBoramae Medical Center, Seoul, South Korea; Seoul National University, Seoul, South Korea; 3 Seoul National University Hospital, Seoul, South Korea; Department of Neuropsychiatry, Hallym University Hangang Sacred Heart Hospital, Hwaseong-si, South Korea; Soonchunhyang University Bucheon Hospital, Bucheon-si, South Korea. Contact e-mail: bksohn1221@hanmail. net

Could mean platelet volume be a promising biomarker of progression of chronic kidney disease?

The mean platelet volume (MPV), a readily available indicator of platelet activation and function, is a useful predictive and prognostic biomarker of cardiovascular and cerebrovascular disease (CVD). It is associated with a variety of prothrombotic and proinflammatory diseases. Larger platelets are more likely to aggregate and release greater quantities of adhesive molecules. MPV has seldom been investigated in patients with chronic kidney disease (CKD). This study aimed to investigate the relationship between MPV levels and the glomerular filtration rate (GFR) in patients with CKD. We reviewed the medical records of patients with CKD who visited the nephrology outpatient clinics of Soonchunhyang University Bucheon Hospital between January 2010 and May 2013. A total of 553 patients were included in the present retrospective study. According to the estimated GFR (eGFR) calculated by the abbreviated the Modification of Diet in Renal Disease (MDRD) equation, the patients were allocated to Group 1 (GFR, 60–89 ml/minute/1.73 m2; n = 64), Group 2 (GFR, 30–59 ml/minute/1.73 m2; n = 268), Group 3 (GFR, 15–29 ml/minute/1.73 m2; n = 147), or Group 4 (GFR, <15 ml/minute/1.73 m2 and non-dialysis; n = 74). Data were analyzed by Student’s t-test, the chi-squared test, Pearson’s correlation coefficient (r), Tukey’s honestly significant difference (HSD) test, and one-way analysis of covariance. The MPV values had a negative correlation with eGFR in patients with CKD (Pearson’s correlation coefficient = −0.553, p < 0.001). The mean MPV values in Groups 1–4 were 9.81 ± 0.13 fl, 10.34 ± 0.08 fl, 10.86 ± 0.09 fl, and 11.19 ± 0.11 fl, respectively (p < 0.001). Multiple comparisons of MPV values in the four groups by Tukey’s HSD test showed statistically significant intergroup differences, with all p values <0.001. Platelet counts and PDW decreased along with eGFR, and there were no significant differences with respect to plateletcrit. Patients with prevalent coronary artery disease (CAD) or CVD had higher MPVs than did those without CAD or CVD. MPV was significantly increased with progression of CKD. MPV may be a useful indicator of increased risks of CAD or CVD in patients with CKD.

A novel ACAD8 mutation in asymptomatic patients with isobutyryl‐CoA dehydrogenase deficiency and a review of the ACAD8 mutation spectrum

A novel <i><scp>ACAD8</scp></i> mutation in asymptomatic patients with isobutyryl‐<scp>CoA</scp> dehydrogenase deficiency and a review of the <i><scp>ACAD8</scp></i> mutation spectrum

The Role of Transnasal Esophagoscopy in ENT Office: A Prospective, Multicenter Study in Korea

ObjectivesThe purpose of study was to report the current role of transnasal esophagoscopy (TNE) in Korea.MethodsOne hundred thirty-seven patients who underwent TNE at Soonchunhyang University Bucheon Hospital (n=69) and Korea University Anam Hospital (n=68) from July 2007 to February 2009 were prospectively analyzed. Laryngopharyngeal reflux disease (LPRD) patients without any response to proton-pump inhibitor (n=102), and patients with complaints that require esophagoscopy as part of their evaluation (n=35) were included in this study; investigation of metachronous lesions or routine follow-up screening of head and neck cancer patients, n=17; dysphagia, n=9; blood tinged saliva, n=4; to determine the cause of vocal fold paralysis as screening tool, n=4; suspicious esophageal foreign body, n=1.ResultsFifty-three patients (38.7%) had positive findings on TNE. Positive finding ratio was highest in group of dysphagia (7 among 9 patients, 78%). Forty-two patients (41.1%) were found to have pathology (esophagitis, n=41; esophageal diverticulum, n=1) during the screening examination for LPRD. There were no significant complications in any of the patients.ConclusionTNE is a high-yield diagnostic and therapeutic modality available to otolaryngologists for use on awake patients in the office setting.

A Validation Study of the Korean Version of Warwick-Edinburgh Mental Well-Being Scale

Sewoong Kim, MD, Han-Yong Jung, MD, PhD, Kyoung-Sae Na, MD, Soyoung Irene Lee, MD, PhD, Shin-Gyeom Kim, MD, A Reum Lee, and Joon Tag Cho Department of Psychiatry, Soonchunhyang University Bucheon Hospital, College of Medicine, Soonchunhyang University, Bucheon, Korea Department of Psychiatry, Gachon University Gil Medical Center, Incheon, Korea Graduate School of Public Administration, Seoul National University, Seoul, Korea

Clinical Characteristics and Metabolic Features of Patients with Adrenal Incidentalomas with or without Subclinical Cushing's Syndrome.

BackgroundThe aim of this study was to examine the clinical characteristics of adrenal incidentalomas discovered by computed tomography (CT) and to investigate metabolic features of subclinical Cushing's syndrome (SCS) in patients with adrenal incidentalomas in a tertiary hospital in Korea.MethodsThis retrospective study examined the clinical aspects of 268 patients with adrenal incidentalomas discovered by CT at Soonchunhyang University Bucheon Hospital. Clinical data and endocrine function of the patients as well as histological findings were obtained from medical records, while anatomic characteristics were analyzed by reviewing imaging studies. Hormonal tests for pheochromocytoma, Cushing's syndrome, and aldosterone-secreting adenoma were performed.ResultsMost (n=218, 81.3%) cases were nonfunctioning tumors. Of the 50 patients with functioning tumors (18.7%), 19 (7.1%) were diagnosed with SCS, nine (3.4%) with overt Cushing's syndrome, 12 (4.5%) with primary aldosteronism, and 10 (3.7%) with pheochromocytoma. Malignant tumors (both primary and metastatic) were rare (n=2, 0.7%). Body mass index, fasting glucose, hemoglobin A1c, and total cholesterol were significantly higher in patients with SCS in comparison with those with nonfunctioning tumors. The prevalence of type 2 diabetes mellitus and hypertension were significantly higher in patients with SCS compared with those with nonfunctioning tumors.ConclusionFunctioning tumors, especially those with subclinical cortisol excess, are commonly found in patients with adrenal incidentalomas, although malignancy is rare. In addition, patients with SCS in adrenal incidentalomas have adverse metabolic and cardiovascular profiles.

Ferritin as a predictor of decline in residual renal function in peritoneal dialysis patients.

Background/AimsAims: Inflammation is an important factor in renal injury. Ferritin, an inflammatory marker, is considered an independent predictor of rapid renal progression in patients with chronic kidney disease. However, the relationship between ferritin and residual renal function (RRF) in patients undergoing peritoneal dialysis (PD) remains unclear.MethodsWe reviewed the medical records of patients who started PD between June 2001 and March 2012 at Soonchunhyang University Bucheon Hospital, Korea. A total of 123 patients were enrolled in the study. At 1 month after the initiation of PD, RRF was determined by a 24-hour urine collection and measured every 6 months thereafter. Clinical and biochemical data at the time of the initial 24-hour urine collection were considered as baseline.ResultsThe RRF reduction rate was significantly greater in patients with high ferritin (ferritin ≥ 250 ng/mL) compared with those with low ferritin (ferritin < 250 ng/mL; -1.71 ± 1.36 mL/min/yr/1.73 m2 vs. -0.84 ± 1.63 mL/min/yr/1.73 m2, respectively; p = 0.007). Pearson correlation analysis revealed a significant negative correlation between the baseline serum ferritin level and the RRF reduction rate (r = -0.219, p = 0.015). Using multiple linear regression analysis and adjusting for other risk factors, baseline serum ferritin was an independent factor for the RRF reduction rate (β = -0.002, p = 0.002).ConclusionsIn this study we showed that a higher ferritin level was significantly associated with a more rapid RRF decline in patients undergoing PD.

Detection of fetal hemoglobin (HbF) using the G8 glycohemoglobin analyzer.

Abnormal HbF concentration has been proposed as a marker of solid tumor and myelodysplastic syndrome. As HbA1c is tested widely for glycemic control monitoring, some commercial glycated hemoglobin assays can provide additional information about these hemoglobin concentrations. However, few studies have investigated the clinical significance of increased HbF in current practice. Between January 2012 and December 2012, HbAlc results, tested in the Department of Laboratory Medicine at Soonchunhyang University Bucheon Hospital, were analyzed. HbAlc was measured using a G8 Glycohemoglobin Analyzer (Tosho Bioscience, Tokyo, Japan) in the 1.6 minutes HbAlc mode. A total of 13,866 specimens from 9,545 patients were tested. The median HbF concentration was 0.7%, the 99.5th percentile was 3.2%, and 73 samples from 56 patients were > 3.2%. Among these patients, 37.5% (21/56) had malignancies: 16 had solid cancer and 5 had hematologic malignancies. The maximum HbF observed was 8.2% and elevated HbF showed no evidence of interference with the HbAlc test. However, the minimum HbF and LA1C+ fraction increased with increasing HbAlc, suggesting interference by elevated HbAlc. Care must be taken when interpreting HbF concentrations in samples with high HbAlc values determined using the HbA1c mode of the G8 Glycohemoglobin Analyzer.

Microscope-Assisted Reconstruction of Canalicular Laceration Using Mini-Monoka

A canalicular laceration is the most common injury of the lacrimal drainage system and can result from direct or indirect injury to the canalicular system. If the wounds are not managed properly, they can lead to scarring, stenosis, and inflammation, which may lead to symptomatic epiphora. We successfully reconstructed canalicular lacerations using Mini-Monoka tubes (FCI Ophthalmics, Marshfield Hills, MA) under microscopic magnification.We treated 14 patients for canalicular lacerations at the Soonchunhyang University Bucheon Hospital between August 2009 and October 2012. All patients underwent placement of a Mini-Monoka tube and a mucosal canalicular anastomosis microscopically to reconstruct monocanalicular lacerations. The tubes were removed at 6 to 8 months postoperatively, and follow-up was 8 to 12 months. No complications related to the Mini-Monoka tube, such as punctual plug migration, eye irritation, inflammation, granuloma formation, or erosion, occurred during the follow-up period.The goal of reconstructing a lacerated canaliculus is accurate approximation of the injured end of the canaliculus to facilitate mucosal healing and to prevent a canalicular obstruction. We believe that microscopic canalicular reconstruction with a Mini-Monoka tube is a safe, reliable, and straightforward method with fewer complications and is more effective for preventing iatrogenic injury in the unaffected canaliculus and minimizing patient discomfort.

Genetic variants in HHIP are associated with FEV1 in subjects with chronic obstructive pulmonary disease

Chronic obstructive pulmonary disease (COPD) is a complex disease in which multiple genes and their interaction with environmental factors contribute to disease development. Recent genome-wide association studies in COPD revealed the chromosome 4 region near hedgehog interacting protein (HHIP). However, these studies were mostly performed in Caucasians, and additional studies in multiple ethnic groups are needed. We investigated genetic associations of HHIP in Korean COPD and control subjects. Two separate case-control studies were performed. Firstly, 139 subjects with COPD and 199 control subjects were selected from the Soonchunhyang University Bucheon Hospital Biobank. Secondly, 219 individuals with COPD were recruited from the Korean Obstructive Lung Disease (KOLD) cohort. The control subjects consisted of 305 smokers or ex-smokers with normal lung function who were registered in the Korean Genome Epidemiology Study. Associations between COPD susceptibility and single-nucleotide polymorphism (SNP) genotypes were tested by logistic regression. Associations between lung function and SNP genotypes were tested by linear regression. In the first study, the mean forced expiratory volume in 1 s (FEV1 ) of these COPD subjects was 1.32 L. None of 15 SNP was significantly associated with COPD susceptibility. However, four SNP associated significantly with FEV1 in subjects with COPD. In the KOLD cohort study, two SNPs (rs11938704 and rs10013495) near HHIP were significantly associated with FEV1 (P = 0.0001 and 0.001, respectively) in subjects with COPD. Genetic variants in HHIP are associated with lung function in subjects with COPD.

Short Term Follow-Up Result of Unilateral Hearing Loss Referred Patient by Newborn Hearing Screening

Received May 27, 2013 Revised September 17, 2013 Accepted September 23, 2013 Address for correspondence Moo Kyun Park, MD Department of OtorhinolaryngologyHead and Neck Surgery, Soonchunhyang University College of Medicine, 170 Jomaru-ro, Wonmi-gu, Bucheon 420-767, Korea Tel +82-32-621-5054 Fax +82-32-621-5440 E-mail aseptic@schmc.ac.kr Background and ObjectivesZZHearing screening is mandatory for newborns. The management of patients who fail hearing screening is important. This study examined the prognosis of patients who had hearing loss detected on the newborn hearing screening. Subjects and MethodZZThe results of newborn hearing tests, follow-up hearing tests, and risk factors for hearing loss were analyzed retrospectively in prospectively collected data. Newborn hearing screening testing using an auto auditory brain stem (ABR) response was performed for 1296 newborns from January 2010 to December 2012 at Soonchunhyang University Bucheon Hospital. Follow-up hearing tests using ABR and otoacoustic emissions were performed 6 and 12 months after the newborn hearing screening. ResultsZZOf the 1296 newborns who underwent hearing screening tests, 63 were referred and 58 had confirmed hearing loss. The hearing loss was unilateral in 74.2% (43/58). During the 1year follow-up, about half of the patients showed improved hearing function. Premature birth was related to hearing recovery. ConclusionZZDuring the follow-up, some patients with unilateral hearing loss showed recovery. Some premature patients can expect hearing recovery during follow-up testing. Regular follow-up after newborn hearing screening is important to detect hearing changes in this period. Korean J Otorhinolaryngol-Head Neck Surg 2013;56:759-63

A Case of Meningoencephalitis due to Relapsing Polychondritis Presenting Cognitive Impairment; Serial Neuropsychological Tests

Department of Neurology, Soonchunhyang University Bucheon Hospital, Bucheon, Korea Central nervous system involvement by relapsing polychondritis is rare. Despite the fact that several reports described its cognitive presentations, the detailed neuropsychological characteristics have not been provided. Severe cognitive impairment was noted in our patient with meningoencephalitis due to polychondiritis. With immunosuppressant therapy, his deficits recovered markedly, but not completely in some severely affected cognitive domains from the earlier time. Neuropsychological complications of polychondritis are very responsive to immunosuppressants although it does not seem to be perfect.

Environmental and Familial Risk Factors of Children and Adolescents with Attention Deficit/Hyperactivity Disorder

MethodsZZChildren and adolescents aged 6-18 with in attention, hyperactivity, or impulsivity who visited the Department of Psychiatry at Soonchunhyang University Bucheon Hospital from April 2006 to April 2012, were interviewed for diagnosis of ADHD. Diagnostic and Statistical Manual of Mental Disorders, 4th edition symptom criteria for ADHD were assessed using a semistructured interview, the schedule for affective disorders and schizophrenia for school-age children present and lifetime version (K-SADS-PL). Environmental and familial variables were obtained using questionnaires for parents.

A Case of Acute Cholecystitis Combined with Eosinophilic Pericarditis Caused by Toxocariasis

Correspondence to Hyun Jong Choi, M.D. Department of Internal Medicine, Soonchunhyang University Bucheon Hospital, 170 Jomaru-ro, Wonmi-gu, Bucheon 420-767, Korea Tel: +82-32-621-5211, Fax: +82-32-621-5080, E-mail: joseph@schmc.ac.kr Copyrightc 2013 The Korean Association of Internal Medicine This is an Open Access article distributed under the terms of the Creative Commons Attribution Non-Commercial License (http://creativecommons.org/licenses/by-nc/3.0/) which permits unrestricted noncommercial use, distribution, and reproduction in any medium, provided the original work is properly cited. 개회충증에 의하여 유발된 호산구성 심장막염을 동반한 급성 담낭염 1예

Therapeutic Outcomes of Endoscopic Submucosal Dissection in Undifferentiated-type Early Gastric Cancer

Endoscopic submucosal dissection (ESD) has been accepted as a standard treatment of early gastric cancer (EGC). However, the indication of ESD in undifferentiated-type EGC was controversial. The aim of this study was to evaluate the therapeutic outcomes of ESD in undifferentiated-type EGC according to expanded indication. At Soonchunhyang University Bucheon Hospital, a total of 82 lesions in 81 patients with undifferentiated-type EGC were treated with ESD. The therapeutic outcomes of ESD were evaluated by resection method (en bloc resection; piecemeal resection), histologic curative resection, complications and recurrence rates after ESD. The rate on en bloc resection and complete resection rate were 87.8% (72/82) and 80.5% (66/82), respectively. In signet ring cell carcinoma, the complete resection rate was higher than those in poorly differentiated adenocarcinoma and poorly differentiated adenocarcinoma with signet ring cell features, but there was no statistical significance (89.3% vs. 75.0%, 76.7%; p=0.347). The lateral margin positivity rate in poorly differentiated adenocarcinoma, signet ring cell carcinoma and poorly differentiated adenocarcinoma with signet ring cell features were 12.5%, 3.6% and 13.3%, respectively (p=0.395). The vertical margin positivity rate were 12.5%, 3.6% and 10.0%, respectively (p=0.485). The overall recurrence rate was 3.0% during a mean follow-up period of 37.4 months. ESD may be considered as a feasible treatment for undifferentiated-type EGC according to expanded indication. The therapeutic outcome of ESD in undifferentiated-type EGC is likely to be favorable, though further longer follow-up studies are needed.

Treatment of Head and Neck Area Pain by Multidisciplinary Approach with Template

Purpose: The headache is a symptom that various somatic or non-somatic disorders gives an effect to head and neck system. The neck and the shoulder pain is a common muscle pain that can not control and bothers the patient after chronic state. The headache and the neck and the shoulder muscle pain are treated with various conventional treatment methods. But, there are cases that symptoms did not resolve or increased in some clinical cases. And generally, the result of temporomandibular disorders (TMD) treatment is good. But, despite of a normal treatment was performed for TMD, there are cases that TMD symptoms did not resolved in clinical cases. In template clinic of Soonchunhyang University Bucheon Hospital, co-operative neurophysiologic treatment of Department of Neurosurgery and Dentistry are done for patients, who had head and neck pain or atypical symptoms that did not treated with various conventional treatment method such as surgery or medication etc. Materials and Methods: Four hundred fifty one patients who have treated in the template clinic, Soonchunhyang University Bucheon Hospital, from January of 2006 to December of 2008 were subjected in this study. Result: Overall average age was 31.9 years old. Ratio of numbers is 74.3% in female and 25.7% in male. The success rate of treatment in TMD symptom was 89.9%, in headache was 88.8%, in muscle pain was 81.6%. Statistically significance of differences visual analogue scale evaluation between before and after had been treated patients who have over average grade headache was calculated by paired t-test. P<0.05 was considered significant. Conclusion: We suggest the template appliance can be attempted for cases whose headache, the neck and the shoulder muscle pain and TMD are not resolved with various conventional treatment methods.