- Email: [email protected]
TREATMENT OF WRITERS' DYSTONIA
1525
addition, this patient had pentazocine ESWL, without ill-effect.
on
three occasions before
Almost all urolithiasis is now treated with ESWL, and until successful medical treatment is available I think we should pay attention not only to the outcome of stone fragmentation, but also to the patient’s comfort. Department of Urology, Yashima General Hospital, 1857-1 Yashima-nishi-machi, Takamatsu Kagawa, 761-01 Japan
YASUO KAWANISHI
1. Goodman and Gilman’s the pharmacological basis of therapeutics, 7th ed. Gilman AG, Goodman LS, Rall TW, Murad F, eds. New York: Macmillan, 1985. 2. Showalter CV. T’s and blues. JAMA 1980; 244: 1224-25. 3. Blazer DG, Haller L. Pentazocine psychosis. Dis Nerv Syst 1975; 36: 404-05. 4. Jackson C, Hart A, Robinson M. Fatal intracranial haemorrhage associated with
phenylpropanolamine, pentazocine and tripelennamine overdose. J Emergency Med 1985; 3: 127-32. Chanamma T, Banks G. Central nervous system complications of addiction to "T’s and blues". Neurology 1982; 32: 623-28. 6. Lahmeyer HW, Steingold RG. Medical and psychiatric complications of pentazocine and tripelennamine abouse. J Clin Psychiatry 1980; 41: 275-78.
more than a minute. With the gripmate he can now write for forty-five minutes before fatigue. We have also had success with this device in 2 other patients. The use of writing aids therefore shows promise in those patients who cannot convert successfully to use of the non-dominant hand for writing and should certainly be considered before botulinus toxin therapy.33
for
National Hospitals for Nervous Diseases, London WC1N 3BG
A. J. LEES BIRGIT KLEEDORFER HEATHER FOSTER
1. Alexander FWM. Writers’ cramp, scriveners’ palsy, functional spasm neurosis affecting physical activities. Med Press Circular 1928; 1: 1-12. 2. Koller W. Usefulness of a writing aid in writers’ cramp. J Neurol Neurosurg Psychiatry 1989; 39: 149. 3. Cohen LG, Hallett M, Geller BD, Hochberg F. Treatment of focal dystonias of the hand with botulinum toxin injections. J Neurol Neurosurg Psychiatry 1989; 52: 355-63.
5. Caplan LR,
TREATMENT OF WRITERS’ DYSTONIA
SIR,-Although the number of people dependent on the craft of writing for their occupation is steadily decreasing, writing difficulties may compromise educational achievement and lead to acute embarrassment in certain everyday activities such as signing cheques. In the past two years one of us (A. J. L.) has seen 31 new cases of writers’ dystonia; 19 were men and 12 were women, mean age of onset 43 (range 28-71 years) with a mean duration of symptoms of 6 years at the time of hospital referral. 3 patients had an associated essential tremor and 1 a spasmodic torticollis; a further patient had Parkinson’s disease and Meige’s syndrome in addition to writers’ dystonia. 1 patient had a family history of essential tremor and another of writers’ cramp. 18 of the patients were clerks and another 5 were involved in professions that required considerable amounts of writing. 11 patients had impairment of finger dexterity for activities such as feeding, using a key, or playing sport, and 2 had an associated writing tremor. Treatment had been unsuccessful. 15 patients had been treated with benzhexol (mean dose 7 mg daily for an average of 6 months), 11with propranolol (80 mg daily for an average of 5 months), and 5 patients had received benzodiazepine with no benefit. Biofeedback had been unsuccessful in 9 patients. 11patients were now writing with their non-dominant hand and 5 had improved their writing by altering their technique. Specific writing aids have been recommended for this disturbance,l and there has been a recent resurgence of interest in this approach. We wish to report the use of a special writing instrument called ’Gripmate’ (Creative Industries, Homecraft Supplies, Kirby in Ashfield, Nottinghamshire) (figure) which was recommended after assessment by our therapy department. A 29-year-old clerk had difficulty in writing with his left hand because of pain and lack of control in May, 1988, during an episode of agitated depression while working for a degree course. He was obliged to hold the pen firmly and exert great pressure in order to write at all; altering his writing technique had not improved matters. He found a thicker pen to be the most helpful strategy. He also noticed some difficulty in sorting out change and in holding his fork. On examination he had a dystonic posture of the left hand when writing and continuously had to take the pen off the page to stretch his fingers. There were no associated signs of basal ganglia disease and no signs of local musculoskeletal injury. He was unable to write
The
gripmate.
OESOPHAGEAL CANCER IN CHINA
SIR,-We were interested in Professor Wahrendorf and colleagues’ paper (Nov 25, p 1239) but they neglect to cite a report dealing with much the same topic. In 1978 the Royal Society sent a delegation (of which we were members) led by Dr M. G. P. Stoker, to China to study certain aspects of oncology, notably the high incidence of oesophageal cancer in Linhsien, several hundred kilometres south-west of Peking. On
our return we wrote
up the infonnation.1
Many of our findings were similar to those of Wahrendorf et al but there are two of interest which the authors do not mention. The first relates to the 1961-76 results of cytological smears, given to us by Dr Hou Chen-ming, vice-director and head of the department of surgery at the Linhsien county hospital: out of 42 190 people aged 30 or more 568 had a positive result. The second is concerned with the fact that the incidence of the carcinomas was closely paralleled by the prevalence of phamygeal carcinoma in chickens, which are "free range" and live largely off domestic scraps. This continued to be so even when a section of the population was displaced from its homeland in a high-incidence area (to permit the construction of a reservoir) and was resettled in what had been a low-incidence area. After migration, the people maintained their accustomed diet and continued to develop the cancer, while their new chickens, which were drawn from stock in the low-incidence area, began to develop the disease. The delegation made several suggestions as to how the causes of the epidemic could be further investigated and possibly removed, and it would be interesting to know whether there has been any progress in that direction. The 1979 report, entitled Scientific visits to China under arrangements between the academion sinica and the Royal Society, may still be available from the Royal Society, 6 Carlton House Terrace, London SWIY 5AG, UK. Department of Genetics and Microbiology, University of Liverpool
CYRIL A. CLARKE
Imperial Cancer Research Fund, Lincoln’s Inn Fields, London WC2A 3PX
WALTER F. BODMER
1. Bodmer WF, Clarke CA. Medical genetics in
China.J Med Genet 1979; 16: 330-37.
CIPROFLOXACIN RESISTANCE AND STAPHYLOCOCCAL ENDOCARDITIS
SIR,-Dr Dworkin and colleagues (Nov 4, p 1071) demonstrate safety and efficacy of a 4-week course of ciprofloxacin and rifampicin, predominantly an oral regimen, for right-sided Staphylococcus aureus endocarditis in intravenous drug users. Although ciprofloxacin alone is effective in experimental S aureus endocarditis,’ Dworkin et al warn of the possible emergence of resistance with single-agent therapy. We have been caring for a patient who had right-sided cloxacillin-sensitive S aureus the
endocarditis. While on antibiotic treatment with ciprofloxacin high-level resistance to the quinolone developed. Clinically this was a therapeutic failure but the organism remained sensitive to cloxacillin and phage susceptibility was unchanged.
addition, this patient had pentazocine ESWL, without ill-effect.
on
three occasions before
Almost all urolithiasis is now treated with ESWL, and until successful medical treatment is available I think we should pay attention not only to the outcome of stone fragmentation, but also to the patient’s comfort. Department of Urology, Yashima General Hospital, 1857-1 Yashima-nishi-machi, Takamatsu Kagawa, 761-01 Japan
YASUO KAWANISHI
1. Goodman and Gilman’s the pharmacological basis of therapeutics, 7th ed. Gilman AG, Goodman LS, Rall TW, Murad F, eds. New York: Macmillan, 1985. 2. Showalter CV. T’s and blues. JAMA 1980; 244: 1224-25. 3. Blazer DG, Haller L. Pentazocine psychosis. Dis Nerv Syst 1975; 36: 404-05. 4. Jackson C, Hart A, Robinson M. Fatal intracranial haemorrhage associated with
phenylpropanolamine, pentazocine and tripelennamine overdose. J Emergency Med 1985; 3: 127-32. Chanamma T, Banks G. Central nervous system complications of addiction to "T’s and blues". Neurology 1982; 32: 623-28. 6. Lahmeyer HW, Steingold RG. Medical and psychiatric complications of pentazocine and tripelennamine abouse. J Clin Psychiatry 1980; 41: 275-78.
more than a minute. With the gripmate he can now write for forty-five minutes before fatigue. We have also had success with this device in 2 other patients. The use of writing aids therefore shows promise in those patients who cannot convert successfully to use of the non-dominant hand for writing and should certainly be considered before botulinus toxin therapy.33
for
National Hospitals for Nervous Diseases, London WC1N 3BG
A. J. LEES BIRGIT KLEEDORFER HEATHER FOSTER
1. Alexander FWM. Writers’ cramp, scriveners’ palsy, functional spasm neurosis affecting physical activities. Med Press Circular 1928; 1: 1-12. 2. Koller W. Usefulness of a writing aid in writers’ cramp. J Neurol Neurosurg Psychiatry 1989; 39: 149. 3. Cohen LG, Hallett M, Geller BD, Hochberg F. Treatment of focal dystonias of the hand with botulinum toxin injections. J Neurol Neurosurg Psychiatry 1989; 52: 355-63.
5. Caplan LR,
TREATMENT OF WRITERS’ DYSTONIA
SIR,-Although the number of people dependent on the craft of writing for their occupation is steadily decreasing, writing difficulties may compromise educational achievement and lead to acute embarrassment in certain everyday activities such as signing cheques. In the past two years one of us (A. J. L.) has seen 31 new cases of writers’ dystonia; 19 were men and 12 were women, mean age of onset 43 (range 28-71 years) with a mean duration of symptoms of 6 years at the time of hospital referral. 3 patients had an associated essential tremor and 1 a spasmodic torticollis; a further patient had Parkinson’s disease and Meige’s syndrome in addition to writers’ dystonia. 1 patient had a family history of essential tremor and another of writers’ cramp. 18 of the patients were clerks and another 5 were involved in professions that required considerable amounts of writing. 11 patients had impairment of finger dexterity for activities such as feeding, using a key, or playing sport, and 2 had an associated writing tremor. Treatment had been unsuccessful. 15 patients had been treated with benzhexol (mean dose 7 mg daily for an average of 6 months), 11with propranolol (80 mg daily for an average of 5 months), and 5 patients had received benzodiazepine with no benefit. Biofeedback had been unsuccessful in 9 patients. 11patients were now writing with their non-dominant hand and 5 had improved their writing by altering their technique. Specific writing aids have been recommended for this disturbance,l and there has been a recent resurgence of interest in this approach. We wish to report the use of a special writing instrument called ’Gripmate’ (Creative Industries, Homecraft Supplies, Kirby in Ashfield, Nottinghamshire) (figure) which was recommended after assessment by our therapy department. A 29-year-old clerk had difficulty in writing with his left hand because of pain and lack of control in May, 1988, during an episode of agitated depression while working for a degree course. He was obliged to hold the pen firmly and exert great pressure in order to write at all; altering his writing technique had not improved matters. He found a thicker pen to be the most helpful strategy. He also noticed some difficulty in sorting out change and in holding his fork. On examination he had a dystonic posture of the left hand when writing and continuously had to take the pen off the page to stretch his fingers. There were no associated signs of basal ganglia disease and no signs of local musculoskeletal injury. He was unable to write
The
gripmate.
OESOPHAGEAL CANCER IN CHINA
SIR,-We were interested in Professor Wahrendorf and colleagues’ paper (Nov 25, p 1239) but they neglect to cite a report dealing with much the same topic. In 1978 the Royal Society sent a delegation (of which we were members) led by Dr M. G. P. Stoker, to China to study certain aspects of oncology, notably the high incidence of oesophageal cancer in Linhsien, several hundred kilometres south-west of Peking. On
our return we wrote
up the infonnation.1
Many of our findings were similar to those of Wahrendorf et al but there are two of interest which the authors do not mention. The first relates to the 1961-76 results of cytological smears, given to us by Dr Hou Chen-ming, vice-director and head of the department of surgery at the Linhsien county hospital: out of 42 190 people aged 30 or more 568 had a positive result. The second is concerned with the fact that the incidence of the carcinomas was closely paralleled by the prevalence of phamygeal carcinoma in chickens, which are "free range" and live largely off domestic scraps. This continued to be so even when a section of the population was displaced from its homeland in a high-incidence area (to permit the construction of a reservoir) and was resettled in what had been a low-incidence area. After migration, the people maintained their accustomed diet and continued to develop the cancer, while their new chickens, which were drawn from stock in the low-incidence area, began to develop the disease. The delegation made several suggestions as to how the causes of the epidemic could be further investigated and possibly removed, and it would be interesting to know whether there has been any progress in that direction. The 1979 report, entitled Scientific visits to China under arrangements between the academion sinica and the Royal Society, may still be available from the Royal Society, 6 Carlton House Terrace, London SWIY 5AG, UK. Department of Genetics and Microbiology, University of Liverpool
CYRIL A. CLARKE
Imperial Cancer Research Fund, Lincoln’s Inn Fields, London WC2A 3PX
WALTER F. BODMER
1. Bodmer WF, Clarke CA. Medical genetics in
China.J Med Genet 1979; 16: 330-37.
CIPROFLOXACIN RESISTANCE AND STAPHYLOCOCCAL ENDOCARDITIS
SIR,-Dr Dworkin and colleagues (Nov 4, p 1071) demonstrate safety and efficacy of a 4-week course of ciprofloxacin and rifampicin, predominantly an oral regimen, for right-sided Staphylococcus aureus endocarditis in intravenous drug users. Although ciprofloxacin alone is effective in experimental S aureus endocarditis,’ Dworkin et al warn of the possible emergence of resistance with single-agent therapy. We have been caring for a patient who had right-sided cloxacillin-sensitive S aureus the
endocarditis. While on antibiotic treatment with ciprofloxacin high-level resistance to the quinolone developed. Clinically this was a therapeutic failure but the organism remained sensitive to cloxacillin and phage susceptibility was unchanged.