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Background Supragastric belching (SGB) may play a role in the pathophysiology of proton pump inhibitors (PPIs)-refractoriness in gastroesophageal reflux disease (GERD). SGB may be present in up to 40% of reflux symptoms in PPI-refractory GERD. Most reports on SGB have come from Western countries, and little is known about the prevalence and relevance of SGB in Asian refractory GERD patients. This study aimed at comparing the role of SGB in GERD patients in Japan and the UK. Methods We re-analyzed impedance-pH monitoring tracings from patients who were referred to tertiary centers in Japan and the UK due to PPI-refractory reflux symptoms. The prevalence of excessive SGB and the impact of SGB on reflux symptoms were compared between the two countries. Results Impedance-pH tracings from124 Japanese and 83 British patients were re-analyzed. Japanese patients were significantly younger and had smaller body mass index than the British (P P = 0.006). Logistic regression analysis showed that the geographical/cultural difference was the only factor associated with the different prevalence of SGB (odds ratio; 2.91, 95% CI 1.09–7.73, P = 0.032). SGB were related to typical reflux symptoms very rarely in Japan [0% (0–4.9)] compared to the UK [35% (0–54.1)] (P = 0.071). Conclusions The prevalence of SGB and their impact on reflux symptoms is significantly lower in Japan compared to the UK. The difference is not related to reflux parameters but might come from ethnic/cultural factors to be further characterized.

We examined whether developing reading skills in the two scripts of Japanese, syllabic Hiragana and morphographic Kanji, had differential effects on underlying cognitive skills. One hundred ninety-one Japanese children (97 girls, 94 boys; Mage = 100.23 months) were assessed on rapid automatized naming (RAN), vocabulary, morphological awareness, visual-spatial skills, Hiragana reading fluency, and Kanji character recognition at the end of Grade 2 and again at the end of Grade 3. Results of cross-lagged analysis showed that Hiragana reading fluency in Grade 2 predicted RAN and visual-spatial skills in Grade 3, and Kanji character recognition in Grade 2 predicted vocabulary in Grade 3, even when the same skills in Grade 2 were controlled. Taken together, these findings suggest that the nature of the script children learn can influence how developing reading skills affect their cognitive underpinnings.

Resolvin D1, a specialized pro-resolving lipid mediator produced from docosahexaenoic acid by 15- and 5-lipoxygenase, exerts anti-inflammatory effects driving to the resolution of inflammation. The present study aimed to elucidate its role in small intestinal damage induced by nonsteroidal anti-inflammatory drug (NSAID). Indomethacin was administered orally to C57BL/6J male mice, which were sacrificed 24 h later to collect small intestine specimens. Before administration of indomethacin, mice were subjected to intraperitoneal treatment with resolvin D1 or oral administration of baicalein, a 15-lipoxygenase inhibitor. Small intestinal damage induced by indomethacin was attenuated by pretreatment with resolvin D1. Furthermore, resolvin D1 reduced the gene expression levels of interleukin-1β, tumor necrosis factor-α, and CXCL1/keratinocyte chemoattractant. Conversely, the inhibition of 15-lipoxygenase activity by baicalein increased the expression of genes coding for these inflammatory cytokines and chemokine, leading to exacerbated small intestinal damage, and reduced the concentration of resolvin D1 in the small intestinal tissue. Exogenous treatment with resolvin D1 negated the deleterious effect of baicalein. 15-lipoxygenase was mainly expressed in the epithelium and inflammatory cells of the small intestine, and its gene and protein expression was not affected by the administration of indomethacin. Inhibition of the resolvin D1 receptor, lipoxin A4 receptor /formyl peptide receptor 2, by its specific inhibitors Boc-1 and WRW4 aggravated indomethacin-induced small intestinal damage. Collectively, these results indicate that resolvin D1 produced by 15-lipoxygenase contributes to mucoprotection against NSAID-induced small intestinal damage through its anti-inflammatory effect.

Non-steroidal anti-inflammatory drugs (NSAIDs) induce small intestinal damage. It has been reported that rebamipide, a mucoprotective drug, exerts a protective effect against NSAID-induced small intestinal damage; however, the underlying mechanism remains unknown. In this study, we investigated the significance of the small intestinal microbiota in the protective effect of rebamipide against indomethacin-induced small intestinal damage in mice. A comprehensive analysis of the 16S rRNA gene sequencing revealed an alteration in the composition of the small intestinal microbiota at the species level, modulated by the administration of rebamipide and omeprazole. The transplantation of the small intestinal microbiota of the mice treated with rebamipide suppressed the indomethacin-induced small intestinal damage. Omeprazole, a proton pump inhibitor, exacerbated the indomethacin-induced small intestinal damage, which was accompanied by the alteration of the small intestinal microbiota. We found that the transplantation of the small intestinal microbiota of the rebamipide-treated mice ameliorated indomethacin-induced small intestinal damage and the omeprazole-induced exacerbation of the damage. These results suggest that rebamipide exerts a protective effect against NSAID-induced small intestinal damage via the modulation of the small intestinal microbiota, and that its ameliorating effect extends also to the exacerbation of NSAID-induced small intestinal damage by proton pump inhibitors.

Patients with asymptomatic esophageal eosinophilia (aEE) do not exhibit clinical symptoms because of esophageal dysfunction, although they have endoscopic and histological findings similar to those of eosinophilic esophagitis (EoE). The cause of the symptoms and the differences between aEE and EoE are unclear. The aim of this study is to determine whether aEE and EoE are same disease entities by comparing immune-related tissue biomarkers using immunohistological staining. Esophageal biopsy specimens from 61 patients, including 18 with aEE and 43 with EoE, were analyzed. Immunofluorescence staining was performed to quantify the immune-related tissue biomarkers such as major basic protein, eosinophil-derived neurotoxin, eotaxin-3, and immunoglobulin G4. Data are presented as median (interquartile range). There were no significant differences in clinical, endoscopic, or histological features, between patients with aEE and EoE, with the exception of body mass index. There were no significant differences in all immune-related tissue biomarkers between both groups. In conclusions, EoE and aEE displayed similar immunohistological profiles. Hence, they may be similar disease entities with some common pathogenic mechanisms. Our findings suggest that patients with aEE also have histopathological esophageal inflammation.

Radiation-induced esophagitis, experienced during radiation therapy for lung cancer and head and neck cancer, is a major dose-limiting side effect of the treatment. This study aimed to elucidate the role of interferon-α (IFN-α) in radiation-induced esophagitis.C57BL/6 mice were exposed to 10 and 25Gy of single thoracic irradiation. Esophageal mucosal damage and inflammatory reactions were assessed for 5 days after irradiation.Irradiation induced esophagitis, characterized by reduction in the thickness of epithelial layer, upregulation of proinflammatory cytokines and chemokines, infiltration of inflammatory cells into the esophageal mucosa, and apoptosis of epithelial cells. Irradiation upregulated the level of gene expression for IFN-α in the esophageal tissue, and the neutralizing antibody against IFN-α ameliorated radiation-induced esophageal mucosal damage, while administration of IFN-α receptor agonist (RO8191) had an inverse effect. Depletion of plasmacytoid dendritic cells (pDCs) by anti-CD317 antibody or pharmacological inactivation with bortezomib suppressed radiation-induced mucosal inflammation and damage, accompanied by decrease in IFN-α expression level.These findings suggest that IFN-α and pDCs exert proinflammatory properties in the pathophysiology of radiation-induced esophagitis.

We examined the cross-lagged relations between word reading fluency in the two orthographic systems of Japanese: phonetic (syllabic) Hiragana and morphographic Kanji. One hundred forty-two Japanese-speaking children were assessed on word reading fluency twice in Grade 1 (Times 1 and 2) and twice in Grade 2 (Times 3 and 4). Nonverbal IQ, vocabulary, phonological awareness, morphological awareness, and rapid automatized naming were also assessed in Time 1. Results of path analysis revealed that Time 1 Hiragana fluency predicted Time 2 Kanji fluency after controlling for the cognitive skills. Time 2 Hiragana fluency did not predict Time 3 Kanji fluency or vice versa after the autoregressor was controlled, but Hiragana and Kanji fluency were reciprocally related between Times 3 and 4. These findings provide evidence for a cross-script transfer of word reading fluency across the two contrastive orthographic systems, and the first evidence of fluency in a morphographic script predicting fluency development in a phonetic script within the same language.

We previously reported that shokyo and kankyo, which are water-extracted fractions of ginger, reduced LPS-induced PGE2 production in human gingival fibroblasts. In this study, we examined the effects of these herbs on LPS-treated mouse macrophage RAW264.7 cells. Both shokyo and kankyo reduced LPS-induced PGE2 production in a concentration-dependent manner. Shokyo and kankyo did not inhibit cyclooxygenase (COX) activity, nor did they alter the expression of molecules in the arachidonic acid cascade. In addition, these herbs did not alter NF-κB p65 translocation into nucleus, or phosphorylation of p65 or ERK. These results suggest that shokyo and kankyo inhibit cPLA2 activity. Although 6-shogaol produced similar results to those of shokyo and kankyo, the concentration of 6-shogaol required for the reduction of PGE2 production were higher than those of 6-shogaol in shokyo and kankyo. Therefore, several gingerols and shogaols other than 6-shogaol may play a role in the reduction of LPS-induced PGE2 production. Thus, 6-shogaol, and other gingerols and shogaols inhibit cPLA2 activity and reduce LPS-induced PGE2 production via a different mechanism from traditional anti-inflammatory drugs. Moreover, kampo medicines that contain shokyo or kankyo are considered to be effective for inflammatory diseases.

Periodontal disease is accompanied by inflammation of the gingiva and destruction of periodontal tissues, leading to alveolar bone loss in severe clinical cases. The chemical mediator prostaglandin E2 (PGE2) and cytokines such as interleukin- (IL-)6 and IL-8 have been known to play important roles in inflammatory responses and tissue degradation. In the present study, we investigated the effects of a kampo medicine, kakkonto (TJ-1), on the production of prostaglandin E2 (PGE2), IL-6, and IL-8 by human gingival fibroblasts (HGFs) treated with lipopolysaccharide (LPS) from Porphyromonas gingivalis. Kakkonto concentration dependently suppressed LPS-induced PGE2 production but did not alter basal PGE2 levels. In contrast, kakkonto significantly increased LPS-induced IL-6 and IL-8 production. Kakkonto decreased cyclooxygenase- (COX-)1 activity to approximately 70% at 1 mg/mL but did not affect COX-2 activity. Kakkonto did not affect cytoplasmic phospholipase A2 (cPLA2), annexin1, or LPS-induced COX-2 expression. Kakkonto suppressed LPS-induced extracellular signal-regulated kinase (ERK) phosphorylation, which is known to lead to ERK activation and cPLA2 phosphorylation. These results suggest that kakkonto decreased PGE2 production by inhibition of ERK phosphorylation which leads to inhibition of cPLA2 phosphorylation and its activation. Therefore, kakkonto may be useful to improve gingival inflammation in periodontal disease.

To test a hypothesis that workers in social Hymenoptera can identify male broods at early stages of development and eliminate them to avert excessive investments in male brood, the ability of larval sex discrimination and the timing of male brood elimination by honeybee (Apis mellifera L.) workers were determined. A comparison between the egg sex ratio and the sex ratio of 5 day-old larvae showed that male larvae might selectively die and/or be eliminated in colonies with low survival rates of broods. Nurse bees conditioned by the extracts of male larval cuticles responded significantly more frequently to male extracts than female ones extracted from 3 and 4–5 day-old larvae. It is known that during the developmental stage of 4–5 days, the weight sharply increases in male larvae. The nurse bees conditioned by the extracts of male comb cells failed to distinguish between male and female extracts. Honeybee workers can thus discriminate the sex of broods for male elimination based on cuticular substances during the larval periods with the highest growth rates, which may avert excessive investments in male brood.

We present two cases of salivary duct carcinoma in this paper. Both cases were middle-aged men. They were treated with total parotidectomy and postoperative radiotherapy. Both cases have been followed up for 18 and 15 months respectively with no evidence of local recurrence or distant metastasis.Sixty-six cases of salivary duct carcinoma, including ours, have been reported in the Japanese literature. We reviewed the clinical characteristics of this unusual tumor. Most cases were male (90%) and occured in the parotid gland (84%). The average age was 61 years, ranging from 36 to 91. In 44% of patients, parotid tumors are accompanied by facial nerve paralysis. Total parotidectomy or extended parotidectomy followed by radiotherapy was the most common treatment for patients with salivary duct carcinoma in the parotid gland. The prognosis was poor and the 5-year survival rate was 28%.

Thirty-nine cases of nasal and paranasal papilloma treated in Tenri Hospital during the last 20 years were reviewed. In 6 cases (15%), squamous cell carcinoma was accompanied by papilloma and all were inverted papilloma. Two were male and 4 were female. The mean patient age in these 6 malignant cases was 73 years old, which was 13 years older than that in benign cases. In the 6 malignant cases, the lesions tended to be more extensive and more often involved the frontal sinus or sphenoid sinus than lesions in benign cases. Clinical symptoms and bone destruction in radiographic studies did not clearly characterize the existence of malignancy.Three cases were preoperatively diagnosed as carcinoma and were treated with a combination of surgery, irradiation and chemotherapy. The other cases were diagnosed as carcinoma from surgically obtained materials and two received postoperative radiotherapy while one case did not. The 3-year survival rate was 80%.

Intrathyroidal parathyroid carcinoma is very rare. To our knowledge, only 2 cases of intrathyroidal parathyroid carcinoma had been reported in Japan. Recently, we encountered a case of hyperfunctioning Intrathyroidal parathyroid carcinoma.A 16-year-old female had complained of thirst, polyposia and polyuria for 6 months. An elastic hard nodule 2 cm in diameter was palpated on the right thyroid lobe. The serum calcium level was 16.2 mg/dl and serum intact-PTH level was 1100 pg/ml (normal value in serum: 10-60 pg/ml). Based on ultrasonography and 201T1 subtraction 99mTc scanning, primary hyperparathyroidism due to a hyperfunctioning parathyroid gland in the right thyroid lobe was suspected. A right lobectomy and local dissection was performed. The tumor was histologically diagnosed as an Intrathyroidal parathyroid carcinoma. The patient was asymptomatic and normocalcemic 29 months after surgery.

Objective To evaluate the parameters associated with significant gastrointestinal (GI) involvement in Henoch-Schönlein Purpura (HSP), and construct a scoring system for the identification of patients at high risk of gross blood in stools. Study design Data for HSP patients hospitalized at each of seven institutes were retrospectively analyzed. Patients were divided into four groups according to the consequent severity of GI involvement. Identification of laboratory parameters at the time of admission were then used to differentiate the groups, and a scoring system to predict gross intestinal bleeding was constructed. Prognostic efficiency, correlation with the subsequent duration of abdominal pain, and association with manifestations excluding abdominal pain were also analyzed. Results An analysis of variance (ANOVA) test showed significant intergroup differences in white blood cell (WBC) count, neutrophil count, serum albumin, potassium, plasma D-dimer and coagulation factor XIII activity. A scoring system consisting of these parameters showed a good prognostic value for gross intestinal bleeding in a receiver operating characteristic (ROC) analysis, and a cut-off value of 4 points showed a sensitivity of 90.0% and specificity of 80.6%. The score was also correlated with the duration of abdominal pain after admission. A significantly higher score (s) was observed in patients presenting with nephritis, although the predictive value was poor. Conclusion A scoring system consisting of generally available parameters was of use in predicting severe GI involvement in HSP patients. Although further study is needed, initial therapy in accordance with disease activity may be taken into consideration using this scoring system.

A rare case of a foreign body in the larynx is reported. The patient was a 67 year-old-male who accidentally inhaled a fruit of cocklebur (Xanthium canadense) into the larynx. The foreign body was located at the anterior part of the right ventricle and was removed uneventfully under local anesthesia using laryngeal forceps and flexible flberscope.

Objective: To ascertain whether prophylactic neck dissection offers an advantage for patients with papillary thyroid carcinoma (PTC) in the absence of clinically metastatic lymphadenopathy.Design: A retrospective study of 108 PTC patients without clinically metastatic lymphadenopathy who were treated at Tenri Hospital between 1977 and 1987. We compared the cumulative non-recurrence rate of cervical metastasis between 68 patients who underwent lymphnode operation (OP group) and 40 patients without any lymphnode operation (non-OP group). There were no significant differences in age and the stages of primary tumors between the two groups. Furthermore, we compared the cumulative non-recurrence rate of cervical metastasis among 40 patients with D0, 26 with D1, 27 with D2 and 2 with D3 dissection and found no significant differences in age and the stages of primary tumors. The mean follow-up period was 16.1±3.0 (MEAN±SD) years.Results: The rate of occult lymphnode metastasis was 79.4% in the OP group. The 20-year non-recurrence rates were 92.6% in the OP group and 87.5% in the non-OP group and generalized Wilcoxon test showed no significant difference between the two groups. The 20-year non-recurrence rates were 87.5% in D0, 92.3% in D1 and 100% in the D2 and D3 dissection group. Generalized Wilcoxon and Logrank tests showed, that there were also no significant differences among them. No patients died of PTC.Conclusion: Although patients with PTC in the absence of clinically metastatic lymphadenopathy had many occult metastases, the frequency of recurrences of cervical metastasis was low. Furthermore, non-recurrence rate in patients without any prophylactic operation was not significantly different compared to patients who underwent some prophylactic dissection. Thus, prophylactic neck dissection does not seem to offer any advantage for patients with PTC in the absence of clinically metastatic lymphadenopathy.

Nineteen cases of hypopharyngeal and cervical esophageal cancer treated primarily with laryngopharyngoesophagectomy and gastric pull-up reconstruction are presented. Thirteen patients received radiotherapy preoperatively, and 4 patients postoperatively.The perioperative morbidity rate was 47% (cutaneous fistula: 21%), reflux: 21%, pyloric stenosis: 11%, but most of the complications were minor. There were no fatal intrathoracic and mediastinal complications.The mean time to oral intake was 26 days and the mean length of hospitalization was 110 days.Although 4 patients had neck nodal recurrences, two of them were salvaged and the others died of intercurrent diseases. Five patients suffered distant relapses that were fatal. No patient had local recurrence. The 5-year survival rate of the hypopharyngeal group and cervical esophagus group was 46% and 49% respectively.Gastric pull-up reconstruction is a safe and effective technique for patients with extensive carcinoma of the hypopharynx and cervical esophagus.

The incidence of functioning thyroid nodules is considered to be low in Japan. However, we perform 123I scintiscan in most cases of thyroid tumors and when thyroid nodules are hot on scintiscan, we advise patients that thyroid nodules should be excised. In this study, we retrospectively reviewed the incidence, diagnostic and operative methods and pathologic characteristics of functioning thyroid nodules from 1991 to 1997 at Tenri Hospital.Among 1177 cases of thyroid diseases in which scintiscans were performed, ninety-one cases (7.7%) had hot nodules and the incidence of functional thyroid nodules is higher than has been reported in Japan.The incidence of euthyroid nodules was higher than expected among those clearly diagnosed as autonomously functioning thyroid nodules by triiodothyronin (T3) suppression test. This result and one false positive case of preoperative fine needle aspiration cytology showed the importance of 123I scintigrams as an initial diagnostic method of thyroid nodules.Thyroid lobectomies or total thyroidectomies were performed in 48 cases. Papillary carcinomas coexisted in eleven cases (22.8%), and four functioning nodules themselves were papillary carcinomas. In consideration of this data and the difficulty of controlling hyperthyroidism due to functioning thyroid nodules, operations should be used as a primary treatment method, even though in our study, postoperative hypothyroidism occurred in ten cases (22.2%) in which thyroid lobectomy was performed.

We have performed glottic closure as a surgical procedure for 35 patients (30 men, 5 women) who had suffered from recurrent aspiration pneumonia since 1985 to 1997. The diseases which caused their aspiration included cerebrovascular disease, degenerative disease, cerebral tumor, ischemic heart disease, myocarditis, tumor of the head and neck region, pulmonary emphysema, tuberculosis etc.Of these 35 cases, 33 patients underwent the glottic closure initially, and 29 cases of the 33 were successful. In the remaining 4 cases, a leakage of saliva was detected after the operation. 3 of these 4 cases then underwent a total laryngectomy, and the last patient had a second glottic closure operation. Two of the 35 cases underwent epiglottic closure, but in both of these cases saliva leakage was detected. One patient underwent a total laryngectomy after all, and another had the glottic closure operation. Both follow-up operations were successful.In all patients, the pneumonia was improved. 29 patients were discharged. 5 patients died in hospital, and 1 is still in hospital.As a glottic closure operation, Montgomery method is widely used. In this method, the laminae of the thyroid cartilage are perforated and sutured with the opposite arytenoid cartilages, and the vocal cords are sutured to each other. However, we use a “simplified” Montgomery method, in which the laminae of the thyroid cartilage are not perforated, and both arytenoid cartilages, the vocal cords and the false cords are sutured to each other. We have achieved good results with this procedure.

Ganglioneuroblastoma is composed of both ganglion and neuroblast cells and is a subset of neuroblastoma, which is one of the most popular malignant tumors of children. This type of tumor typically originates from the abdomen and rarely from the neck. We report a case of cervical ganglioneuroblastoma in this article.A 9 year-old girl was presented as having an elastic hard tumor in the left side of her neck. The tumor located behind the bifurcation of the common carotid artery and no blood flow was detected by either ultrasonic study or magnetic resonance imaging. We performed extirpation of the tumor as a neurinoma, and carried out an additional neck dissection after the tumor was diagnosed as a ganglioneuroblastoma by pathologic study of a frozen section of the tumor. Its origin was thought to be the cervical sympathetic trunk.Complete surgical resection is sufficient treatment for cervical ganglioneuroblastoma in children because it can be detected earlier than abdominal tumors and because radiation therapy and chemotherapy have serious side effects on children.

Paraganglioma is not a particularly rare type of tumor, but intravagal paraganglioma is very rare. We recently treated a case of intravagal paraganglioma arising in the parapharyngeal space. A 70 year-old male was examined following complaints of infra-auricular swelling. A preoperative carotid angiogram revealed that the tumor had high vascularity and that the carotid bifurcation was not widened. We were able to remove the tumor transcervically with a partial submandibulectomy. Postoperatively, the patient complained only of hoarseness.

An inverted papilloma in the frontal sinus is a rare finding. We recently treated an 81-year-old female with malignant transformation of an inverted papilloma in the frontal sinus.We performed the tumor resection with a transfrontal sinus approach and a transnasal approach, followed by radiation therapy.To our knowledge, there have been no previous reports of an inverted papilloma in the frontal sinus undergoing malignant transformation.

Purpose: After neck dissection, where the accessory nerve is often excised patients usually complain of impaired shoulder movements. The accessory nerve forms a plexus with branches of the cervical nerves C2, C3, and C4. In the present study, the accessory nerve was examined during neck dissections to clarify the incidence of motor fibers in joining branches, and the function of the motor fibers was evaluated postoperatively in relation to shoulder movements. Materials and Methods: Presence of cervical contributions to the accessory nerve were examined in 20 neck sides in 15 patients. Postoperative function of the shoulder movements was evaluated by manual muscle testing (MMT) and electromyography (EMG). Results: Motor fibers in cervical contributions were noted on four sides (20%) by stimulation of joining branches. When the accessory nerve was excised, scapular elevation was rarely impaired even if there were no motor fibers in the cervical contributions. Excision of the accessory nerve caused poor scapular adduction and impaired scapular depression and adduction in most cases even if motor fibers in the cervical contributions existed. Conclusion: Postoperative impairment of scapular movements was not attributed to the presence or absence of motor fibers in joining branches. Results obtained with electromyography did not represent the practical function of the muscle.

Extramedullary plasmacytoma is a rare disease, which arises most commonly in the head and neck. We have recently treated a 34-year-old male with multiple occurences of extramedullary plasmacytoma originating in the epipharynx, posterior pharyngeal wall, tonsils and larynx. Histopathologic studies revealed to be a IgG-κ producing plasmacytoma.It has been reported that radiation therapy is the most effective treatment for extramedullary plasmacytoma, but surgical therapy was useful in this radio-resistant case.

A rare case of pleomorphic adenoma of the cervical esophagus is reported. A 65-year-old woman visited our hospital complaining of something sticking in her throat. An upper gastrointestinal series and the endoscopic examination showed a pedunculated mass lesion of the cervical esophagus. It was removed surgically and a histological examination revealed a pleomorphic adenoma.

Postoperative recurrent hyperthyroidism was studied in 25 out of 171 patients who underwent subtotal thyroidectomy for Graves' disease. Mean weight of the remnant thyroid tissue was 6.5±0.9 grams and mean follow-up time was 31.8±16.2 postoperative months. Fifteen (60%) of the patients needed antithyroid drugs after recurrence, but the doses of the drugs were small in most patients. Of the 15 patients, 5 (33%) entered remission due to antithyroid drugs. The appropriate weight of remnant thyroid is thought to be 6 grams, but it should be less than 6 grams in children and the patients who are resistant to antithyroid drugs before surgery. As the status of thyroid function may change over long periods, long-term follow-up is needed.

Patients with tinnitus were treated with Ternelin® (tizanidine hydrochloride) alone or in combination with Hydergine® (dihydroergotoxine mesylate). The following results were obtained.1) When overall improvement was assessed at the end of the dosing period, 36% of the 136 patients who received Ternelin and Hydergine® (the combined therapy group) showed moderate or marked improvement, while 61.8% of the patients in this group showed slight, moderate or marked improvement. The combined therapy was rated as moderately or highly useful in 35.3% and slightly to highly useful in 61% of all cases.2) Of the 24 patients who received Ternelin alone (the solo therapy group), 25% showed moderate or marked improvement, and 66.7% showed slight, moderate or marked improvement. Solo therapy was rated as moderately or highly useful in 25% and slightly to highly useful in 66.7%.3) of the 153 patients who received combined therapy (including 17 patients who were only included in the safety assessment), 9 developed adverse reactions (3 cases of drowsiness, and one each of orthostatic syncope, hypotonia, dizziness, gastric pain, constipation and oral thirst). None of the patients given Ternelin® alone showed any adverse reactions.4) The percentage of cases showing marked or moderate improvement was higher in the combined therapy group than in the solo therapy group, although this difference was not significant. In the ombined therapy group, the reduction in tinnitus peaked 2 to 4 weeks afterr the start of treatment. In the solo therapy group, the number of patients responding to the drug increased gradually with time, and more time was needed to obtain maximal effects than that in the combined therapy group.

The “so-called shoulder syndrome” occurs frequently after neck dissection. However, some patients whose accessory nerves were sacrificed during operation have normal shoulder mobility. There is some controversy about whether the cervical nerves to the accessory nerve innervate the trapezius muscle.Using a neurostimulator, we examined the motor innervation of the cervical contributions during operation. After neck dissection, we examined the function of the trapezius muscle with manual muscle testing (MMT) and electromyography (EMG) and correlated the results with whether or not the accessory nerve had been preserved.In eight of 42 sides (19%) motor fibers from the cervical nerves reached the trapezius muscle. Scapular elevation was not greatly restricted even if the accessory nerve had been sacrificed, presumably because of the compensatory function of the levator scapulae muscle. Motor action potentials of the inferior fibers of four trapezius muscles were present even after the accessory nerve on that side had been sacrificed. It appears, therefore, that the inferior fibers of the trapezius muscle can be innervated by nerves other than the accessory nerve.