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Bilateral adrenalectomy, in experienced hands, is a relatively safe and useful management option in patients with hypercortisolism. Growth of a pituitary adenoma post-operatively is now the most worrying complication.

NSAIDs significantly reduce overall pain over 4 weeks. This short-term responsiveness is retained, and even after several years of therapy with tiaprofenic acid pain scores increased over 2 weeks when it was changed to placebo. Our results do not show long-term benefits from the use of NSAIDs in OA and the majority of patients had persisting pain and disability despite therapy.

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.

Seventy‐nine patients underwent subtotal or total adrenalectomy for pituitary‐dependent Cushing's syndrome (1953–1980); 76 survived the operation and 75 were followed for 1 to 27 (mean 11) years. Pigmentation, plasma ACTH, and sellar X‐rays were assessed at intervals. Pigmentation developed in 37 (5 before and 32 after operation), most frequently after total adrenalectomy. The sella was definitely enlarged in 6 of 65 patients before the operation and in 14 of 65 after it. Enlargement was more common in pigmented than in non‐pigmented patients. The plasma ACTH concentration rose after adrenalectomy. It was significantly higher in pigmented than in non‐pigmented patients. It was also higher after total than after subtotal adrenalectomy. Pituitary tumors were confirmed histologically in 15 patients. The tumors presented at the same time as the Cushing's syndrome in 8 and after adrenalectomy in 7. They were malignant and fatal in 6. Pigmentation, present in 11 of these patients, developed only after adrenalectomy. In 9 other patients with benign lesions and 21 with clinically probable but histologically unconfirmed tumors, 7 were treated by hypophysectomy with or without irradiation (4 cured, 3 improved), and 4 by irradiation alone: external 3, internal 1 (all improved).

One hundred and thirty seven previously untreated outpatients with first and second degree haemorrhoids were allocated at random to treatment by infrared coagulation (n=66) or rubber band ligation (n= 71). Complete follow up was obtained in 122 patients (60 who had undergone infrared coagulation (group 1), and 62 rubber band ligation (group 2)) at periods from three months to one year after completion of treatment.Infrared coagulation produced a satisfactory outcome in 51 patients (85%): 34 were rendered asymptomatic and 17 improved. Rubber band ligation produced a satisfactory outcome in 57 patients (92%): 33 were rendered asymptomatic and 24 improved. Both methods were equally effective in first and second degree haemorrhoids. The incidence of side effects, particularly discomfort, during and after treatment was significantly higher in those treated by rubber band ligation (p <0 001). This appeared to be an appreciable deterrent to future patient compliance. The number of patients losing more than 24 hours from work was higher after rubber band ligation than after infrared coagulation. The number of treatments necessary to cure symptoms did not differ significantly between the two methods. Infrared coagulation