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Fig 1-Mean changes in blood flow, diastolic diameter, and distensibility ofbrachial artery in 12 diabetic subjects and 12 controls during reactive hyperaemia, 1Oug glyceryl trinitrate, and 400 ,ug glyceryl trinitrate. Bars show 95% confidence intervals (9) mm Hg; blood flow 45 (28) v 49 (41) m/min; diastolic diameter 482 (0 60) v 4-47 (1P05) mm; distensibility 4-8 (1-4) v 5 9 (1-6) per kPa). During reactive hyperaemia, heart rate, blood pressure, and the increase in brachial artery blood flow (5548% (99 5%) v 590% (106&6%)) were similar in diabetic and normal subjects (figure 1) but the increases in brachial artery diastolic diameter (1 2% (2-7%) v 9-1% (4-4%); difference 6-9% (95% confidence interval 4.9% to 11%)) and distensibility (-15-3% (10-4%) v 31% (31-7%); difference 46-3% (25-5% to 67<1%)) were significantly less in diabetic subjects (both P < 0-00 1). After 10 ,ug glyceryl trinitrate or 400 ,ug glyceryl trinitrate the increase in flow, diameter, and distensibility was similar in diabetic and normal subjects (figure 1). 700-Comment Endothelium dependent, flow related dilatation and increase in distensibility of the brachial artery are greatly impaired in patients with non-insulin dependent diabetes, but endothelium independent responses induced by glyceryl trinitrate are similar to those in normal subjects. Loss of flow related increase in arterial distensibility will augment systolic pressure, myocardial wall stress, and heart work relative to stroke output, potentially promoting left ventricular hypertrophy and lowering ischaemic threshold. Late systolic pressure will be further augmented by early wave reflection from the periphery3 because pulse wave velocity is increased when distensibility is reduced. Loss of flow mediated vasodilatation reflects endothelial dysfunction and may thus also provide a marker of atherogenetic susceptibility. Our data provide evidence ofvascular dysfunction in non-insulin dependent diabetes before the appearance of microalbuminuria, previously regarded as its earliest marker.4We thank Dr J R Peters for allowing us to study patients under his care and Wendy Simons and Julie-Ann Davies for their secretarial assistance.Funding: British Heart Foundation. Conflict of interest: None.

A case-control study was conducted to study the association between breast-feeding and inguinal hernia. The case group was significantly less often breast fed than control subjects (odds ratio, 0.49; 95% confidence interval, 0.29 to 0.83) and exclusive breast-feeding was associated with a significant dose-response risk reduction. The association was not confounded by birth weight, maternal education, type of birth, number of other children in the family, or gender. Breast-feeding may represent a protective factor against inguinal hernia.

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