SummaryVitamin-B,, malabsorption has been found in 21 (30%) of 71 diabetic patients taking long-term metformin therapy in addition to dietary management. The patients with evidence of B12 malabsorption had significantly lower haemoglobin levels (and significantly higher serum folic acid levels) than those with normal B1 absorption. Steatorrhoea was found in only one patient. Stopping metformin therapy resulted in reversion of B1 absorption to normal in most patients examined. Four patients with B12 malabsorption were found to have pathologically low serum B,2 levels. The causes and implications of these findings are discussed and it is concluded that all patients on long-term metformin therapy should have annual serum B12 estimations.

SUMMARY Phaeochromocytomas were diagnosed in 72 patients in Hammersmith, Beljiast and Newcastle between 1955 and 1976. Fourteen

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SUMMARYThe long-term (2-15 years) results of treatment of a consecutive series of 60 patients with Cushing's syndrome are analysed. Of 41, in whom no evidence of tumour was found initially, 12 were eventually found to have tumours in the pituitary (including 3 suspected), the adrenal, or the bronchus.Most of the 46 with benign lesions (adrenal hyperplasia, without evidence of malignant tumour, or adrenal adenoma) were treated by adrenalectomy with an operative mortality of 4 per cent. All who survived operation underwent remission. One-quarter died within 3 years, but thereafter the proportion that survived remained fairly constant (between 64 and 76 per cent) up to 15 years. Cushing's syndrome recurred in 1 1 per cent (3 patients) of those having subtotal adrenalectomy. I n each case the recurrence was treated effectively. Two of 9 patients with benign pituitary adenomas were cured by transfrontal hypophysectomy and packing of the fossa with yttrium 90.Fourteen patients had malignant tumours of the pituitary, the adrenal, or the bronchus and all died within 5 years. Five of these had invasive pituitary tumours which failed to respond to various combinations of hypophysectomy and irradiation.Arterial hypertension and serious cardiovascular lesions were found initially in 93 per cent and 40 per cent, respectively. Adrenalectomy lowered the pressure effectively and permanently. The average postoperative systolic pressure was about normal and the average diastolic pressure was within 10 mm. Hg of normal. Some cardiovascular lesions resolved, but * Formerly Professor of Surgical Science, Queen's University of Belfast.

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A 23-year-old female presented with severe Cushing's syndrome in the 23rd week of pregnancy. Investigations showed plasma cortisol 770 nmol/l (08.00 h) and 850 nmol/l (23.00 h); plasma ACTH was 10 ng/l (08.00 h) and 27 ng/l (23.00 h); urinary free cortisol excretion was 2460 nmol/24 h. Dexamethasone 2 mg 6-hourly for 48 h suppressed the 08.00 h plasma cortisol only to 680 nmol/l. Abdominal C.T. scan showed a right adrenal adenoma. The patient was treated with metyrapone and a good clinical improvement ensued. Plasma cortisol was reduced to 300-500 nmol/l. Depsite ultrasonographic evidence of normal fetal growth, urinary oestriol excretion was markedly deficient. Prior to the spontaneous onset of labour, there was a marked rise in plasma cortisol despite continuous metyrapone treatment. A normal female infant was born at 37 weeks' gestation. The maternal adrenal adenoma was subsequently removed. The deficiency of oestriol synthesis during the pregnancy may be explained by metyrapone-induced inhibition of C19-hydroxylation.