SUMMARY To assess the clinical significance of coronary artery ectasia 4993 consecutive coronary arteriograms were reviewed to identify patients with this condition and to allow the assessment of their progress. Coronary ectasia was a relatively uncommon finding (overall incidence 1-4%). It was not related to the development of aortic aneurysms and did not affect the outcome, results of coronary artery surgery, or symptoms.Coronary artery ectasia has been a well recognised, if uncommon, pathological finding for many years.'The advent of cardiac catheterisation allowed the diagnosis to be made in life, and associations have been reported with trauma,2 polyarteritis nodosa,3 Takayasu's disease,4 mucocutaneous lymph node syndrome,5 congenital abnormalities,6 and syphilis. In westem populations the most common association is with atherosclerotic coronary artery disease. Estimates of the incidence of coronary ectasia have varied from 0 3%7 to 4-7%.8 As definitions of ectasia in the various published series are similar these differences may reflect differences between the populations studied, observer bias, or random variation in the smaller series. Most published series suggest that the incidence in patients investigated for ischaemic heart disease is between 1% and 2-5%(1.2% 910 1*3%," 1-5%, 12 2.2%/ 13 and 2-5%14).The clinical significance of coronary ectasia is not clear. It has been suggested that the presence of ectasia alone is as important as the presence of coronary artery stenosis.9 Another study showed no difference from a control population with ischaemic heart disease.8 An association with aortic aneurysm has also been reported,"5 although most series do not mention any relation between the two. It has been said that the presence of ectasia does not affect the outcome of coronary bypass grafting unless the graft is sutured into the wall of the ectatic segment.'3We reviewed a large series of patients undergoingRequests for reprints to Dr G G Hartnell, Department of Radiology, Hammersmith Hospital, Du Cane Road, London W12 OHS.Accepted for publication 2 July 1985 coronary angiography to determine the incidence of coronary ectasia. In addition, we tried to assess its clinical significance, especially in terms of mortality and effect on coronary artery surgery. Patients and methodsOver the period 1976-82 all coronary angiograms at this hospital were reported by the same two radiologists (usually together but sometimes singly). Coronary artery ectasia was diagnosed when a segment of artery was more than 1-5 times the diameter of adjacent normal segments of artery (Figs. a and b). The case notes of those patients who were diagnosed as having ectasia were reviewed to assess the distribution of ectasia and associated stenosis and obtain details of subsequent cardiac surgery, aortic aneurysm, death, or other cardiac events. Where patients had been followed elsewhere details were requested from the patient's general practitioner. Full follow up data were available on 47 of the 70 patients with ectasia.

An outbreak of Salmonella typhimurium infection in a large general hospital is described. The outbreak was spread over some 20 weeks and gave rise to 102 cases of enteritis and there were at least 150 symptomless excreters of the organism.Evidence is presented to support the view that the method of spread was by cross-infection, not by contamination of food in bulk. Control measures, which ultimately brought the outbreak to an end, were instituted on this basis.We wish to thank Dr A. J. H. Tomlinson and his staff at the Public Health Laboratory, County HallS.E. 1 for the generous assistance they gave us in examining all the specimens from the hospital staff during the outbreak. The resources of the Department of Bacteriology of the Postgraduate Medical School were at that time largely devoted to teaching and adequate investigations could not have been made without this help. Dr Tomlinson also gave us much advice both during and after the outbreak for which we are most grateful.Dr E. S. Anderson, Director of the Central Enteric Reference Laboratory and Bureau, Colindale, London, N.W. 9, very kindly undertook the phage-typing of many of the strains of Salmonella typhimurium isolated and we wish to express our thanks to him for this and other help he gave us in the investigation of the outbreak.Our thanks are also due to Dr Joan Taylor, Director of the Salmonella Reference Laboratory, Colindale, for her help and interest.Discussions with Dr R. M. Fry and Dr Joan Boissard in Cambridge in connexion with their investigations of a similar outbreak were most interesting and valuable and it gives us pleasure to thank them.We also acknowledge gratefully the help and co-operation of our colleagues at Hammersmith Hospital, especially Dr C. E. Roberts, the Medical Superintendent, and of those at the Postgraduate Medical School.

Echocardiography of the mitral valve in patients with hypertrophic obstructive cardiomyopathy has revealed an abnormal pattern of movement. The abnormality is characteristic, readily recognized, and can be explained in anatomical and physiological terms. It consists of a sharp reopening of the valve during systole when it should normally remain in the fully closed position. This abnormal movement mirrors the mid-systolic onset of both outflow tract obstruction and mitral regurgitation. It was only absent in the two patients with the disease in whom both mitral regurgitation and outflow tract obstruction were also absent. A second and less striking abnormality was a reduced diastolic closure similar to that seen in mitral stenosis and attributed to slow left ventricular filling. The echo from the septum is also unduly prominent.

No abstract

The frequency of hiatus hernias found incidentally during routine barium meal examinations has been reported on many occasions (Eisen, 1938;Levy and Duggan, 1941;Mendelsohn, 1946;Root and Pritchett, 1938;and Ritvo, 1930), and varies between 0-8% and 2-9%. When the abdominal pressure is increased by any method during the examination, the incidence rises to between 2-1% and 11 8% (Boyd, Harris, Butler, and Donaldson, 1956;Carmichael, 1959;Conway-Hughes, 1956;Sim, 1964;and Hafter, 1958). Stein and Finkelstein (1960), Texter, Van Derstappen, Chejfec, Chvojka, Vidinli, Barborka, and Bundesen (1962), and Wolf and Guglielmo (1957 have shown that even more hernias can be demonstrated if the patient is given barium to swallow when in the prone position with the abdomen compressed. METHODTo find the incidence of hiatus hernia when each patient having a barium meal is given barium to swallow whilst lying prone, 500 consecutive barium meals were studied. All the examinations were done to establish the cause of abdominal pain believed to be due either to peptic ulceration or to gastric neoplasm. Meals which were given to confirm the presence of a clinically suspected hiatus hernia were not included in the 500, nor were those merely to estimate progress of a known gastric ulcer or examinations on patients who had already had gastric surgery. If a hiatus hernia had not already been seen before completing each examination, a single mouthful of barium was given whilst the patient lay prone over a firm bolster some 9 in. in diameter. The barium was watched on the screen as it moved down the oesophagus, and the oesophageal peristaltic waves were examined particularly to see if they continued as far as the diaphragm or not. Gastro-oesophageal reflux was not diagnosed unless the oesophagus filled from below, that is, without giving barium in the prone position. A film was taken of the oesophagus after it had emptied as much as it would and a hiatus hernia was diagnosed only if a ring or groove as described by Maclean (1959) could be identified above the diaphragm and the mucosal pattern of the supradiaphragmatic pouch was continuous with that of the infradiaphragmatic portion of the stomach. When doubt existed on the evidence of either the screening or the film about the presence of a hernia none was reported. RESULTSThe frequency of hiatus hernias for each decade is shown in Table I. The overall incidence is 29-6%. Gastro-oesophageal reflux occurred in 57 of the 148 (38 %) patients with hiatus hernia and was seen in 41 women (45% of those with hernias) and 16 men (29 %).