995
monella, or gonococcal antibodies or infectious mononucleosis proved to be negative in the ELISA test. ELISA can be used as a specific, sensitive, and reproducible assay of rheumatoid factor. However, further standardisation is necessary.
as
for
most ELISA
tests,
Department of Medical Microbiology, Institute Medical Laboratories and Ignatius Hospital, Breda, Netherlands
F. TH. C. WILLEMS C. C. M. KLAASSEN DE KORT
since they may have no further seizures. Case 3 is now classified correctly, but he was incorrectly classified at his school medical. Although only a very small sample, these cases raise a number of questions: are c.M.o.s properly trained to make these very important decisions; are equally inappropriate restrictions being applied to children with other chronic conditions ; and should not the medical records of all children be reviewed just before they leave school, because their state of health may have changed? I thank Dr R. Wilson and Dr M.
Roxby
for advice and encourage-
ment.
EPILEPSY AND THE SCHOOL LEAVER’S MEDICAL
SiR,--One of the duties of a clinical medical officer (c.M.o.) is the medical examination of pupils in their last year of comeducation. This is the last routine school medical examination the adolescent will have even though he or she may stay on for two years or more. The c.M.o. has to decide if the school leaver’s subsequent employment should be restricted in any way. Any restrictions are entered on a special form (Y9). Where a pupil has or has had a chronic illness the decision can be difficult. If restrictions are enforced the adolescent may find some forms of employment closed to him, so the decision is important. Problems often arise with epilepsy, and I decided to review the records of children labelled as epileptic in the borough in which I was working. Of 20 281 children in ordinary State schools, 49 were labelled as epileptic, and 7 of these had had school leavers’ medicals:
for Sick Children, London WC1N 3JH
Hospital
DAVID ELLIMAN
pulsory
Case 1.-Girl of 17. Nocturnal seizures between the ages of 12y and 13. Since her first seizure she had been on continuous anticonvulsants. School leavers’ medical at age 15. Case 2.-Boy of 16. One seizure at age 12 in association with rubella encephalitis. Since then he has been on anticonvulsants continuously. At the time of his school leavers’ medical (age 16y) he was being weaned off them. Case 3.-Boy of 16. Two seizures in association with encephalitis at age 9 years. He had been on continuous medication until, after slow reduction, this was stopped very recently. School leavers’ medical at age 15, before anticonvulsants were tapered off. Case 4.-Boy of 16. Seizures at age 8 and 12. Since the second seizure he has been on continuous medication and is seizure-free. School leavers’ medical at age 15. Case 5.-Girl of 16 who started having "funny turns" at age 7. She was put on anticonvulsants. At age 14 medication was stopped and it was decided the "turns" had been fainting episodes rather than seizures. At a school leavers’ medical when 16 years old, she had been free of "turns" and off medication for 2 years. Case 6.-Boy of 15 2. Started having seizures when aged 10 and is now fairly well-controlled on medication though he still has occasional seizures. School leavers’ medical at 15 2 Case 7.-Boy of 16 who had his only seizure at age lly. He had been on medication from then until it was discontinued at about age 15. He has had no further seizures and his school leavers’ medical was done at age 15(9 months after treatment stopped).
On the Y9s of all these pupils except case 7 the c.M.o. had stated: "In my opinion this pupil is not suitable for work at heights or near vehicles in action". Leaving aside the question of the original diagnosis and treatment, at the time of their medicals all but cases 2 and 7 would have been legally entitled to a full driver’s licence (assuming they were old enough and had no other disabilities). Logically therefore, any employment restrictions in cases 1, 3, 4, 5, and 6 might not seem justifiable. Case 2 would not be eligible for a licence so some restrictions might be iri order. Case 3 would not now be eligible for a drivers’ licence and so, while restrictions may not have been justifiable at the time of his medical, they would now. As case 7 had been off treatment for only 9 months before his medical, restrictions could well be
On the
StR,—The results described by Dr Millar Craig and his colp. 797) are not only of practical but also of theoretical interest. The enormous fall of arterial presgreat sure during sleep was a great surprise to us when we first observed it using the first fully automatic apparatus for recording arterial pressure in the absence of an observer.’ The size of the fall was amply confirmed when we used Dr Stott’s improved apparatus,2 also used by Millar Craig and others. (Why did they not refer to the earlier paper whose results they confirmed ?) The cardiovascular changes during sleep were analysed by my colleagues.3 They are usually attributed to the change in the activity of the reticular formation in the brain. Have Millar Craig and his colleagues plotted blood-pressure and pulse together on the same graph? If so, did the changes parallel one another? They should have, if they severally reflect the activity of the reticular formation.
leagues (April 15,
5 Horwood Close,
Headington, Oxford OX3 7RF
criterion of
eligibility for a drivers’ licence being unfairly restricted; case 7 should, perhaps have some restrictions imposed but has not; and cases 2, 3, and 6 are justifiably restricted. However, cases 2 and 7 should be reviewed 2 years after medication has been stopped simple
1, 4, and 5
were
GEORGE PICKERING
SiR,—We have demonstrated4-6 that the most important determinants of blood-pressure variability over a 24 h period are physical activity and sleep. We were therefore surprised that Dr Millar Craig and his colleagues did not seem to take physical activity into sufficient account in their analysis of changes in blood-pressure in the early morning. From their grouped data it is impossible to determine when their patients awoke; in our experience such patients often awaken early in the morning, and it is inconceivable that they would all awaken simultaneously. We found no significant rise in bloodpressure before awakening, but we did find that, after awakening, pressure rises but is further affected by physical activity. The figure represents group data on eighteen patients (average age 40, range 21-58) who had continuous intra-arterial blood pressure recorded over 24 h.7 Casual blood-pressure averaged 150/96 mm Hg (range 120/70 to 230/120) and all were untreated at the time of study. To clarify the influence of sleep and awakening we determined the time at which each patient woke and used that as our reference point. Blood-pressure was then averaged over 30 min periods backwards throughout 1.
D. W., Honour, A. J., Fenton, G. W., Stott, F. W., Pickering, G. W. Clin. Sci., 1964, 26, 445. 2. Bevan, A. T., Honour, A. J., Stott, F. H. ibid, 1969 36, 329. 3. Bristow, J. D., Honour, A. J., Pickering, T. G., Sleight, P. Cardiovasc. Res.
Richardson,
1969, 3, 476. Littler, W. A., Honour, A. J., Carter, R. D., Sleight, P. Br. med. J. 1975, iii, 346. 5. Littler, W. A., Honour, A. J., Pugsley, D. J., Sleight, P. Circulation, 1975, 51, 1101. 6. Littler, W. A., West, M. J., Honour, A. J., Sleight, P. Am. Heart J. 1978, 95, 180. 7. Littler, W. A., Honour, A. J., Sleight, P., Stott, F. D. Br. med. J. 1972, iii, 4.
justified. cases
CIRCADIAN VARIATION IN BLOOD-PRESSURE
76.
’
monella, or gonococcal antibodies or infectious mononucleosis proved to be negative in the ELISA test. ELISA can be used as a specific, sensitive, and reproducible assay of rheumatoid factor. However, further standardisation is necessary.
as
for
most ELISA
tests,
Department of Medical Microbiology, Institute Medical Laboratories and Ignatius Hospital, Breda, Netherlands
F. TH. C. WILLEMS C. C. M. KLAASSEN DE KORT
since they may have no further seizures. Case 3 is now classified correctly, but he was incorrectly classified at his school medical. Although only a very small sample, these cases raise a number of questions: are c.M.o.s properly trained to make these very important decisions; are equally inappropriate restrictions being applied to children with other chronic conditions ; and should not the medical records of all children be reviewed just before they leave school, because their state of health may have changed? I thank Dr R. Wilson and Dr M.
Roxby
for advice and encourage-
ment.
EPILEPSY AND THE SCHOOL LEAVER’S MEDICAL
SiR,--One of the duties of a clinical medical officer (c.M.o.) is the medical examination of pupils in their last year of comeducation. This is the last routine school medical examination the adolescent will have even though he or she may stay on for two years or more. The c.M.o. has to decide if the school leaver’s subsequent employment should be restricted in any way. Any restrictions are entered on a special form (Y9). Where a pupil has or has had a chronic illness the decision can be difficult. If restrictions are enforced the adolescent may find some forms of employment closed to him, so the decision is important. Problems often arise with epilepsy, and I decided to review the records of children labelled as epileptic in the borough in which I was working. Of 20 281 children in ordinary State schools, 49 were labelled as epileptic, and 7 of these had had school leavers’ medicals:
for Sick Children, London WC1N 3JH
Hospital
DAVID ELLIMAN
pulsory
Case 1.-Girl of 17. Nocturnal seizures between the ages of 12y and 13. Since her first seizure she had been on continuous anticonvulsants. School leavers’ medical at age 15. Case 2.-Boy of 16. One seizure at age 12 in association with rubella encephalitis. Since then he has been on anticonvulsants continuously. At the time of his school leavers’ medical (age 16y) he was being weaned off them. Case 3.-Boy of 16. Two seizures in association with encephalitis at age 9 years. He had been on continuous medication until, after slow reduction, this was stopped very recently. School leavers’ medical at age 15, before anticonvulsants were tapered off. Case 4.-Boy of 16. Seizures at age 8 and 12. Since the second seizure he has been on continuous medication and is seizure-free. School leavers’ medical at age 15. Case 5.-Girl of 16 who started having "funny turns" at age 7. She was put on anticonvulsants. At age 14 medication was stopped and it was decided the "turns" had been fainting episodes rather than seizures. At a school leavers’ medical when 16 years old, she had been free of "turns" and off medication for 2 years. Case 6.-Boy of 15 2. Started having seizures when aged 10 and is now fairly well-controlled on medication though he still has occasional seizures. School leavers’ medical at 15 2 Case 7.-Boy of 16 who had his only seizure at age lly. He had been on medication from then until it was discontinued at about age 15. He has had no further seizures and his school leavers’ medical was done at age 15(9 months after treatment stopped).
On the Y9s of all these pupils except case 7 the c.M.o. had stated: "In my opinion this pupil is not suitable for work at heights or near vehicles in action". Leaving aside the question of the original diagnosis and treatment, at the time of their medicals all but cases 2 and 7 would have been legally entitled to a full driver’s licence (assuming they were old enough and had no other disabilities). Logically therefore, any employment restrictions in cases 1, 3, 4, 5, and 6 might not seem justifiable. Case 2 would not be eligible for a licence so some restrictions might be iri order. Case 3 would not now be eligible for a drivers’ licence and so, while restrictions may not have been justifiable at the time of his medical, they would now. As case 7 had been off treatment for only 9 months before his medical, restrictions could well be
On the
StR,—The results described by Dr Millar Craig and his colp. 797) are not only of practical but also of theoretical interest. The enormous fall of arterial presgreat sure during sleep was a great surprise to us when we first observed it using the first fully automatic apparatus for recording arterial pressure in the absence of an observer.’ The size of the fall was amply confirmed when we used Dr Stott’s improved apparatus,2 also used by Millar Craig and others. (Why did they not refer to the earlier paper whose results they confirmed ?) The cardiovascular changes during sleep were analysed by my colleagues.3 They are usually attributed to the change in the activity of the reticular formation in the brain. Have Millar Craig and his colleagues plotted blood-pressure and pulse together on the same graph? If so, did the changes parallel one another? They should have, if they severally reflect the activity of the reticular formation.
leagues (April 15,
5 Horwood Close,
Headington, Oxford OX3 7RF
criterion of
eligibility for a drivers’ licence being unfairly restricted; case 7 should, perhaps have some restrictions imposed but has not; and cases 2, 3, and 6 are justifiably restricted. However, cases 2 and 7 should be reviewed 2 years after medication has been stopped simple
1, 4, and 5
were
GEORGE PICKERING
SiR,—We have demonstrated4-6 that the most important determinants of blood-pressure variability over a 24 h period are physical activity and sleep. We were therefore surprised that Dr Millar Craig and his colleagues did not seem to take physical activity into sufficient account in their analysis of changes in blood-pressure in the early morning. From their grouped data it is impossible to determine when their patients awoke; in our experience such patients often awaken early in the morning, and it is inconceivable that they would all awaken simultaneously. We found no significant rise in bloodpressure before awakening, but we did find that, after awakening, pressure rises but is further affected by physical activity. The figure represents group data on eighteen patients (average age 40, range 21-58) who had continuous intra-arterial blood pressure recorded over 24 h.7 Casual blood-pressure averaged 150/96 mm Hg (range 120/70 to 230/120) and all were untreated at the time of study. To clarify the influence of sleep and awakening we determined the time at which each patient woke and used that as our reference point. Blood-pressure was then averaged over 30 min periods backwards throughout 1.
D. W., Honour, A. J., Fenton, G. W., Stott, F. W., Pickering, G. W. Clin. Sci., 1964, 26, 445. 2. Bevan, A. T., Honour, A. J., Stott, F. H. ibid, 1969 36, 329. 3. Bristow, J. D., Honour, A. J., Pickering, T. G., Sleight, P. Cardiovasc. Res.
Richardson,
1969, 3, 476. Littler, W. A., Honour, A. J., Carter, R. D., Sleight, P. Br. med. J. 1975, iii, 346. 5. Littler, W. A., Honour, A. J., Pugsley, D. J., Sleight, P. Circulation, 1975, 51, 1101. 6. Littler, W. A., West, M. J., Honour, A. J., Sleight, P. Am. Heart J. 1978, 95, 180. 7. Littler, W. A., Honour, A. J., Sleight, P., Stott, F. D. Br. med. J. 1972, iii, 4.
justified. cases
CIRCADIAN VARIATION IN BLOOD-PRESSURE
76.
’
